HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 1211 OSGOOD STREET 8/5/2024 Commonwealth of Massachusetts
City/Town of North Andover U%
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:
1211 Osgood Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Apiehak Lots Of Eats
Name
1211 Osgood Street
Address(if different from location)
North Andover MA 01845
City/Town State Zip Code
2078078343
Telephone Number
B. Pumping Record
1. Date of Pumping 07/15/2024 2 Quantity Pumped: 200.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑ septic Tank Fj 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:
[Kitchen] : . Metal trap mod rust stainless. 10" H2O. 6" SOL. 6" GRS. Gasket OK.
Extra Services : . Pumped 1 trap, couldn't finish all the way because they were
using it as I waspumping. Did you check in and out? : Unchecked. No
signature/store stamp.
6. System Pumped By:
Imani Archie
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
Imani Archie 07/15/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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