HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 419 ANDOVER STREET 10/10/2023 Commonwealth of Massachusetts
City/Town of North Andover C L
System Pumping Record t 1
Form 4
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:
419 Andover,
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Starbucks
Name
85 Wells Avenue, Suite 110
Address(if different from location)
Newton Center MA 02459
City/Town State Zip Code
5084775806
Telephone Number
B. Pumping Record
1. Date of Pumping 09/20/2023 2 Quantity Pumped: 100.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank ❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes � No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
[3 Bay Sink] : . Plastic trap 35 gallons. 4" H2O. 5" SOL. 4" GRS. Left 0 btl
solution. Gasket OK. BOH logs signed. Extra Services : . pumped ltrap 35 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
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