HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 267 CHICKERING ROAD 3/5/2024 Commonwealth of Massachusetts
P37 % 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. tbe
substantially the same as that provided here. Before using this form,check with your local Board of Hqa�h16-dkermine the form
they use.The System Pumping Record must be submitted to the local Board of Health or other apptoAng authority within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location: MpR \t
267 Chickering Road, Rte 125 e
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Restaurant Ninety Nine
Name
14A Gill Street
Address(if different from location)
Woburn MA 01801
City/Town State Zip Code
9783728303
Telephone Number
B. Pumping Record
1. Date of Pumping 02/19/2024 2. Quantity Pumped: 3500.0000
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? 0 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:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
Robert Herrick 02/19/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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