HomeMy WebLinkAboutGrease Trap - License - 1264 OSGOOD STREET 3/5/2024 Commonwealth of Massachusetts
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City/Town Of North Andover a
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be<jj 1,but the informationl. gust be
substantially the same as that provided here.Before using this form,check with yo&1bcal Board of HJ ItK to determine tW,%rm
they use.The System Pumping Record must be submitted to the local Board of Health or other wing authority,,%ki sv14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
1264 Osgood Street
Address
North Andover MA 01845
Cityrrown 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 02/21/2024 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank FX-]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:
Normal water level. Sin bottom sludge. 3in 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:
Robert Herrick
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
Robert Herrick 02/21/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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