HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 1264 OSGOOD STREET 3/5/2024 Commonwealth of Massachusetts P060*0
City/Town of North Andover0 �
System Pumping Record
Form 4 5 �0
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 determi
they use.The System Pumping Record must be submitted to the local Board of Health or other approving author,. 14
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
City/Town State Zip Code
2. System Owner:
Starbucks
Name
85 Wells Avenue, Suite 110
Address(if different from location)
Newton Center MA 02459
CitylTown State Zip Code
5084775806
Telephone Number
B. Pumping Record
02/26/2024 200.0000
1. Date of Pumping Date 2• Quantity Pumped: 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. 4" H2O. 24" SOL. 24" GRS. Gasket OK. BOH logs
signed. Extra Services : . [3 Bay Sink] : . Good condition. 8" H2O. 2" SOL. 2" 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:
02/26/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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