HomeMy WebLinkAboutSeptic Pumping Slip - Starbucks - 11/27/2024 - Septic Pumping Slip - 1264 OSGOOD STREET 11/27/2024 Commonwealth of Massachusetts
City/TownOf North Andover
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 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. Facillit,%, Information
'y
1. System Location:
_L2_64 Q.__ s�92od Street
Address
North Andover MA 01845
City/Town Zp Cgdv__---
2. System Owner:
Starbucks
Name ............ -------
85 Wells Avenue, Suite 110
Address(if different from location)
Newton Center MA 02459
Cityrrown State Zip Code
8007827282
Telephone Number
B. Pumping Record
11/27/2024 ____, 1500.0000
.................................
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank F71 Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? E]Yes No If yes, was it cleaned? Fj Yes Fj No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Grease Tank system serviced. Filter not
present. Tank cannot be outfitted with filter. 1500 gallons removed. 5 inches of
bottom sludge. 2 inches of grease on top. 1 inches of water. System is at proper
working level. Both baffles/tees are intact. Main line is clear. Couldn't get a
Signature or use store phone took pics.
6. System Pumped By:
Jerald Brilhante
-Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
NENO Yard: 163 Western Ave, Gloucester, MA 01930
Jerald Brilhante 11/27/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1