HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 93 TURNPIKE STREET 5/7/2024 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 MAC ti02
1. System Location:
93 Turnpike Road
Address
North Andover MA '`''01845
City/Town State Zip Code
2. System Owner:
Rubicon
Name
125 Half Mile Road, Suite 201
Address(if different from location)
Red Bank NJ 07701
City/Town State Zip Code
7322753434
Telephone Number
B. Pumping Record
1. Date of Pumping 04/05/2024 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 FX-] No If yes, was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
[3 Bay Sink] : . Plastic trap in good condition. 8" H2O. 6" SOL. 6" GRS. Gasket OK.
BOH logs signed. Extra Services : . Pump and clean 1 plastic trap in good
condition. Did you check in and out? : Unchecked. No signature/store stamp.
6. System Pumped By:
Joao Varela
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780
04/05/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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