HomeMy WebLinkAboutGrease Trap - Sprinkler Permit - 93 TURNPIKE STREET 1/8/2024 Commonwealth of Massachusetts %tip'LQ
City/Town of North Andover �p1�
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information mustbe
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 afuthority within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
93 Turnpike Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Rubicon
Name
125 Half Mile Road, Suite 201
Address(if different from location)
Red Bank NJ 07701
City/Town State Zip Code
7322753434
Telephone Number
B. Pumping Record
1. Date of Pumping 12/07/2023 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 0 No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
[3 Bay Sink] : . Plastic. 4" H2O. 6" SOL. 6" GRS. Gasket OK. BOH logs signed. Extra
Services : . Clean 1 trap. Did you check in and out? : Unchecked. Got
signature/store stamp.
6. System Pumped By:
Walburt Wallace
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
12/07/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover S
System Pumping Record
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:
93 Turnpike Road
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
Rubicon
Name
125 Half Mile Road, Suite 201
Address(if different from location)
Red Bank NJ 07701
City/Town State Zip Code
7322753434
Telephone Number
B. Pumping Record
1. Date of Pumping 10/12/2023 2 Quantity Pumped: 3000.0000
Date Gallons
3. Component: cesspool(s) ❑ Septic Tank Tight Tank 0 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes a No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Normal water level. Sin bottom sludge. 5in top solids. Both baffles are intact.
Main line Clear. No filter is present on the tank; current tank is not designed to
be used with a filter. Cover(s) secured. No 3rd party paperwork filled.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
NENO Yard: 163 Western Ave, Gloucester, MA 01930
10/12/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record GPI a
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:
93 Turnpike Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Rubicon
Name
125 Half Mile Road, Suite 201
Address(if different from location)
Red Bank NJ 07701
City/Town State Zip Code
7322753434
Telephone Number
B. Pumping Record
1. Date of Pumping 10/06/2023 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 0 No If yes,was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
[3 Bay Sink] : . Good condition. 6" H2O. 6" SOL. 8" GRS. Gasket OK. BOH logs signed.
Extra Services : . Pumped and cleaned. Did you check in and out? : Unchecked. No
signature/store stamp.
6. System Pumped By:
Vilton Marques
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
10/06/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1
\ Commonwealth of Massachusetts
City/Town of North Andover
-_ - System Pumping Record
Form 4
J- 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:
93 Turnpike Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Rubicon _
Name
125 Half Mile Road, Suite 201
Address(if different from location)
Red Bank NJ 07701
Cityrrown State Zip Code
7322753434
Telephone Number
B. Pumping Record
1. Date of Pumping 08/28/2023 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? ElYes No
5. Observed condition of component pumped:
[3 Bay Sink] : . Good condition. 4" H2O. 8" SOL. 8" GRS. Gasket OK. BOH logs signed.
Extra Services : . Pumped and cleaned 1 plastic grease trap. Did you check in and
out? : Unchecked. No signature/store stamp.
6. System Pumped By:
Vilton Marques
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
08/28/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1