HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 93 TURNPIKE STREET 6/11/2025 Commonwealth of Massachusetts
w� City/Town of North Andover
s
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:
93 Turnpike Road
Address
North Andover MA 01845
City/Town State Zip Code
2. System Owner:
Rubicon
Name
125 Half Mile Road, Suite 201
Address(if different from location)
Red Bank NJ 07701
City/Town State Zip Code
7322753434
Telephone Number
B. Pumping Record
1. Date of Pumping 06/11/2025 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. 10 inches of grease on top. 14 inches of water. 10 inches of bottom
sludge. 50 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. Pumped one grease trap. BOH Logs Signed.
6. System Pumped By:
Terrill Todman
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Holbrook WRE Yard: 24 South Street, Holbrook, MA 02343
Terrill Todman 06/11/2025
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1