HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 535 CHICKERING ROAD 1/31/2024 Commonwealth of Massachusetts
F 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 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:
535 Chickering Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Cafua Management Company, LLC
Name
280 Merrimack Street
Address(if different from location)
Methuen MA 01844
City/Town State Zip Code
5087369622
Telephone Number
B. Pumping Record
1. Date of Pumping 01/31/2024 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 ❑X No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
[3 Bay Sink) : . Good condition. 10" 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:
Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780
01/31/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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