HomeMy WebLinkAboutStarbucks Grease Trap - Septic Pumping Slip - 419 ANDOVER STREET 1/22/2025 Commonwealth of Massachusetts
City/Town Of North Andover own of IVOtth 4 ndo ver
System Pumping Record
Form 4 FEB
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must b 2025
substantially the same as that provided here.Before using this form,check with your local Bo of Health to determine the form
they use.The System Pumping Record must be submitted to the local Board of Health or of
within 14
days from the pumping date in accordance with 310 CMR 15.351. 6
A. Facility Information
1. System Location:
419 Andover
Address
North Andover MA 01845
City/Town
2. System Owner:
Starbucks
................
Name
85 Wells Avenue, Suite 110
-Address(if differentfrom location)
Newton Center MA 02459
City/Town State Zip Code
8007827282
Telephone Number
B. Pumping Record
1. Date of Pumping 01/22/2025 2. Quantity Pumped: 100.0000
Date Gallons
3. Component: F-1 Cesspool(s) n Septic Tank F]Tight Tank Q Grease Trap
F"] Other(describe):
4. Effluent Tee Filter present? M Yes [X-] No If yes, was it cleaned? F]Yes No
5. Observed condition of component pumped:
3 Bay Sink. 3 inches of grease on top. 6 inches of water. 3 inches of bottom
sludge. 35 gallons removed. Both baffles/tees are intact. Gasket is in bad
condition - Recommend replacing gasket. Grease trap needs 2 bolts replaced.
Walls/bottom of trap are in need of repair. Recommend Trap Repair/Replace. System
is at proper working level. Left 0 bottles of drain master. One bolt missing, 1
6. System Pumped By:
Joshua Melendy
................. ------
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
-................... ...... ...........
Joshua Melendy 01/22/2025
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record-Page 1 of 1