HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 562 TURNPIKE STREET 1/3/2024 Commonwealth of Massachusetts
City/Town Of North Andover
- System Pumping Record �a
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:
562 Turnpike Street
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
Starbucks
Name
85 Wells Avenue, Suite 110
Address('rf different from location)
Newton Center MA 02459
Citylrown State Zip Code
5084775806
Telephone Number
B. Pumping Record
1. Date of Pumping 10/03/2023 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 0 No If yes,was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
[3 Bay Sink] : . Good plastic. 3" H2O. 5" SOL. 2" GRS. Left 0 btl solution. Gasket
OK. BOH logs signed. Extra Services pumped ltrap 25. 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:
10/03/2023
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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