HomeMy WebLinkAboutGrease Trap-Panera - Septic Pumping Slip - 58 PETERS STREET 4/1/2025 Commonwealth of Massachusetts
w� City/Town of North Andover
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System Pumping Record
Form 4
M� 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. Facility Information
1. System Location:
58 Peters Street
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
PR Restaurants LLC / Panera Bread
Name
2150 Washington Street, Suite 125
Address(if different from location)
Newton Lower Falls MA 02462
City/Town State Zip Code
7746013210
Telephone Number
B. Pumping Record
1. Date of Pumping 04/01/2025 2. Quantity Pumped: 100.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank Tight Tank ❑X 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:
3 Bay Sink. 3 inches of grease on top. 7 inches of water. 3 inches of bottom
sludge. 35 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 0 bottles of drain master. BOH Logs Signed.
6. System Pumped By:
Gabriel Mckinney-Dias
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
04/01/2025
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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