HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 315 TURNPIKE STREET 6/6/2024 (3) <�, 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:
315 Turnpike Street
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
9786822382 x743
Telephone Number
B. Pumping Record
1. Date of Pumping 05/22/2024 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:
[3 Bay Sink] : . Mod rust. 6" H2O. 4" SOL. 4" GRS. Gasket OK. BOH logs signed. Extra
Services : . Pumped and cleaned 1 trap. Did you check in and out? : Unchecked.
Got signature/store stamp.
6. System Pumped By:
Raymond Saez
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Inside Grease - NEMO Yard: 54 Knox Trail, Acton, MA 01720
Raymond Saez 05/22/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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