HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 267 CHICKERING ROAD 5/8/2025 Commonwealth of Massachusetts
City/TownOf North Andover
System Pumping Record
R
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. Facility Information
1. System Location:
267 ChickerinQ Road, Rte 125
............................
Address
North Andover MA 01845
St,pte
2. System Owner:
,Ninety Nine Restaurant
Name
14A Gi.11. Street
-------------------------- ................................ ................ .......................-----------
Address(if different from location)
Woburn MA 01801
-&.............. ...................................................... ..............................City/Town State Zip Code
6172428999
Telephone Number
B. Pumping Record
05/08/2025 3500.0000
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank RX Grease Trap
R Other(describe):
4. Effluent Tee Filter present? QYes Z No If yes, was it cleaned? n Yes F-] 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. 3500 gallons removed. 24 inches of
bottom sludge. 24 inches of grease on top. 30 inches of water. System is at proper
working level. Both baffles/tees are intact. Main line is clear.
6. System Pumped By:
Jaime Rivera
-i4a—m—e --- Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough,_MA 01752
Company
7. Location where contents were disposed:
MEMO Yard: 54 Knox Trail, Acton, MA 01720
............ —------
Jaime Rivera 05/08/2025
............. ..............
Signature of Hauler Date
- " - '' ' J--6'Jl -----'------ ---- .........................................Signeiureof Racaivnecility(or attach facility receipt) Date
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