HomeMy WebLinkAboutSeptic Pumping Slip - 58 Peters St - Panera - 10/01/2024 - Septic Pumping Slip - 58 PETERS STREET 10/1/2024 Commonwealth of Massachusetts
C' Onf North Andover
System Pumping Record
Form
DEP has provided this form for use by local Boards vfHealth.Other forms may ue used,but the information must oe
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 m accordance with 31OCwR 15.351.
A. Facility Information
1. System Location:
58 Peters Street
Address
North Andover M& 01845
City/Town -State -41
2. System Owner:
PR Restaurants LLC Panera Bread
Name
2150 Washington Street, Suite 125
*w4neme(if different from location)
Newton Lower Falls MA 02462
City/Town 8iate Zip Code
7746013210
Telephone Number
B. Pump.ng Record
lO/Ol/2O24 I00.0000
1 Date 2 Quantity' Date ' � Gallons
3. Component [—lCesspool(s) F-7 Septic Tank [—1 TightTank F�� Grease Trap
��
L� Other(deaoribe):
4. Effluent Tee Filter present? F—lYes No |f yes,was itcleaned? F—1 Yes [—lNo
5. Observed condition of component pumped:
Cover was accessed and properly secured. oitobeu, 4 iurbeo of grease on top. 24
ioouee of water. 3 ioobea of bottom sludge. 60 gallons removed. Both baffles/tees
are intact. Gasket is in good condition. walla/bottom of trap in good 000diti^o,
System is at proper working level. Left O bottles of drain master. aue Logs
Signed.
G. System Pumped By:
ZG AnthonyTzabu000
Name Vehicle License Number
SuiteWind River Environmental, 46 Lizotte Drive, OUOMarlboro bf MA Ol752
Company
7. Location where contents were disposed:
Holbrook WRE Yazd; 24 South Street, Holbrook, M& 02343
IG Anthony Tzabooco 10/01/2024
SiQnomneofHauler Date
nature n/Receiving Facility(or attach facility receipt) Date
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