HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 1085 OSGOOD STREET 6/6/2024 <�, 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
1. System Location:
1085 Osgood Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
OR20 Restaurant/Cafe Trattoria IG
Name
1085 Osgood Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
9786866921
Telephone Number
B. Pumping Record
1. Date of Pumping 05/25/2024 2. Quantity Pumped: 100.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank FX—] 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:
[Kitchen] : . Plastic. 10" H2O. 14" SOL. 14" GRS. Gasket OK. BOH logs signed. Extra
Services : . Pumped and cleaning lx greace trap. Did you check in and out?
Unchecked. No signature/store stamp.
6. System Pumped By:
Thiago Domingos
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Vanguard Renewables - Located in Haverhill: 1058 Boston Road, Haverhill, MA
Thiago Domingos 05/25/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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