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Commonwealth of Massachusetts
City/Town of North Andover f> 2024
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 Mustbee,
substantially the same as that provided here.Before using this form,check with your local Board of Health to determines tifie 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
Citylrown State Zip Code
2. System Owner:
ORZO 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 09/12/2024 2. Quantity Pumped: 100.0000
Date Gallons
3. Component: Fj Cesspool(s) Septic Tank F1 Tight Tank ❑X Grease Trap
Other(describe):
4. Effluent Tee Filter present? Ej Yes Z No If yes,was it cleaned? 0 Yes F] No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Kitchen. 6 inches of grease on top. 10
inches of water. 6 inches of bottom sludge. 40 gallons removed. Both baffles/tees
are intact. Gasket is in good condition. Walls/bottom of trap in good condition.
System is at proper working level. Left 8 bottles of drain master. BOH Logs
Signed.
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:
Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780
Thiago Domingos 09/12/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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