HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 58 PETERS STREET 7/3/2025 <L row/? Of AlorthAndover
Commonwealth of Massachusetts
City/Town Of North And.ve,
System Pumping Record AUG
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used, i rmation must be e q to determine the form
substantially the same as that provided here.Before using this form,check with your local M%
they use.The System Pumping Record must be submitted to the local Board of Health or other appro ithin 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 Stag-----
2. System Owner:
PR Restaurants LLC / Panera Bread
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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 0 7/0 3/2 0 2 5—__ 2. Quantity Pumped: 100.0000 ............................
Date Gallons
3. Component: Cesspool(s) F] septic Tank F-]Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? F-]Yes No If yes, was it cleaned? F-1 Yes No
5. Observed condition of component pumped:
3 Bay Sink. 3 inches of grease on top. 25 inches of water. 3 inches of bottom
sludge. 40 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. None. BOH Logs Signed.
6. System Pumped By:
Marcus Spencer
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
Marcus Spencer 07/03/2025
Signature of Hauler Date
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Signature of Receiving Facility(or attach facility receipt) Date
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