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HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 1085 OSGOOD STREET 1/8/2024 Commonwealth of Massachusetts 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: 1085 Osgood Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: ORZO Restaurant/Cafe Trattoria IG Name 1085 Osgood Street Address(if different from location) North Andover MA 01845 . City/Town State Zip Code 9786866921 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 Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑Yes ❑X No If yes,was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: [3 Bay Sink] : . Plastic. 6" H2O. 4" SOL. 4" 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 System Pumping Record Form 4 e% 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: 1085 Osgood Street Address North Andover MA 01845 City/Town State Zip Code__ 2. System Owner: ORZO Restaurant/Cafe Trattoria IG Name 1085 Osgood Street Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9786866921 Telephone Number B. Pumping Record 1. Date of Pumping 11/09/2023 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] : . Good condition. 2" H2O. 8" 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: 11/09/2023 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 " 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: 1085 Osgood Street Address North Andover MA 01845 City/Town State Code 2. System Owner: ORZO Restaurant/Cafe Trattoria IG Name 1085 Osgood Street Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9786866921 Telephone Number B. Pumping Record 1. Date of Pumping 10/13/2023 2 Quantity Pumped: 100.0000 Date Gallons 3. Component: Fj Cesspool(s) Fj 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] : . Good condition. 2" H2O. 8" SOL. 6" 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: 10/13/2023 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 F� City/Town Of North Andover �ti0ti�` 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: 1085 Osgood Street Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: ORZO Restaurant/Cafe Trattoria IG Name 1085 Osgood Street Address(if different from location) North Andover MA 01845 Cityrrown State Zip Code 9786866921 Telephone Number B. Pumping Record 1. Date of Pumping 08/28/2023 2. Quantity Pumped: 100.0000 Date Gallons 3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? Yes ❑ No 5. Observed condition of component pumped: [3 Bay Sink] : . Good condition. 4" H2O. 6" SOL. 6" 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