HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 1264 OSGOOD STREET 5/16/2025 Town of North
Commonwealth of Massachusetts Andover
JUN
City/Town of North Andover 3 2o25
System Pumping Record
Form 4HC'alth
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the infornl /�
substantially the same as that provided here.Before using this form,check with your local Board of Health to determine tf5e 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:
1264 Osgood Street _
Address
North _Andover_ MA 01845
CityCrown LL State _ Zip Code —
2. System Owner:
Starbucks
Name
85 Wells Avenue, Suite 110
Address(if different from location) v
Newton Center ------------ MA 02459 —�
City/Town State Zip Code
4133274959
Telephone Number
B. Pumping Record
05/16/2025 1500. -------
Date
3. Component: ❑ Cesspool(s) n Septic Tank ❑Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes n No If yes, was it cleaned? n Yes n 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. 8 inches of
bottom sludge. 8 inches of grease on top. 25 inches of water. System is at proper
working level. Both baffles/tees are intact. Main line is clear..
6. System Pumped By:
Jaime Rivera _
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
Jaime Rivera 05/16/2025
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12 System Pumping Record•Page 1 of 1