HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 58 PETERS STREET 10/10/2023 Commonwealth of Massachusetts
F City/Town of North Andover
System Pumping Record
Form 4
M DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must be
substantially the same as that provided here.Before using this form,check with your local Board of Health to determine the form
they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
58 Peters Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
PR Restaurants LLC / Panera Bread
Name
2150 Washington Street, Suite 125
Address(if different from location)
Newton Lower Falls MA 02462
Citylrown State Zip Code
4135931800
Telephone Number
B. Pumping Record
1. Date of Pumping 09/20/2023 2 Quantity Pumped: 100.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank X❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes [X No If yes, was it cleaned? ElYes ❑ No
5. Observed condition of component pumped:
(3 Bay Sink] : . plastic trap 50 gallons. 6" H2O. 5" SOL. 3" GRS. Left 0 btl
solution. Gasket OK. BOH logs signed. Extra Services : . pumped ltrap 50 gallons.
Did you check in and out? : Unchecked. No signature/store stamp.
6. System Pumped By:
Tony Clemons
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
09/20/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1