HomeMy WebLinkAboutSeptic Pumping Slip - 562 Turnpike Commonwealth of Massachusetts
City/Town of North Andover
�I �
System Pumping Record , °: �12Q24
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the in"
{drmation must be
substantially the same as that provided here.Before using this form,check with your local Board of Health to*tertnine the form
they use.The System Pumping Record must be submitted to the local Board of Health or other approving authont�wit fir}-4"h
days from the pumping date in accordance with 310 CMR 15.351. °C
A. Facility Information
1. System Location:
562 Turnpike Street
Address
North Andover MA 01845
Cityrrown State Zip Code
2. System Owner:
Starbucks
Name
85 Wells Avenue, Suite 110
Address(if different from location)
Newton Center MA 02459
City[Town State Zip Code
5084775806
Telephone Number
B. Pumping Record
1. Date of Pumping 09/16/2024 2. Quantity Pumped: 100.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑Tight Tank 0 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:
Cover was accessed and properly secured. 3 Bay Sink. 2 inches of grease on top. 6
inches of water. 2 inches of bottom sludge. 20 gallons removed. Both baffles/tees
are intact. No gasket is present. Walls/bottom of trap in good condition. System
is at proper working level. Left 0 bottles of drain master. No visible issues when
completing EMG service, water flow into trap good. Trap filling properly, no
6. System Pumped By: -
Liam Brown
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
Liam Brown 09/16/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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