HomeMy WebLinkAboutGrease Trap - Septic Pumping Slip - 93 TURNPIKE STREET 8/29/2025 Town of North Andover
Commonwealth of Massachusetts
City/TownOf North Andover SEP 16 2025
.......... System Pumping Record
Form 4 Health
D
DFP�has provided this form for use by local Boards of Health.Other forms may be used,but the information 2PNOMetit
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:
pike Road
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Address
North Andover MA 01845
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2. System Owner:
Rubicon
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Name
125 Half Mile Road, Suite 201
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Address(if different from location)
Red Bank NJ 07701
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City/Town State Zip Code
7322753434
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Telephone Number
B. Pumping Record
08/29/2025 100.0000
1. Date of Pumping Date ......... 2. Quantity Pumped: -di Flon-s-
3. Component: Cesspool(s) F-] septic Tank F]Tight Tank �Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? Yes Yes No If yes, was it cleaned? [-]Yes [—] No
5. Observed condition of component pumped:
3 Bay Sink. 4 inches of grease on top. 6 inches of water. 4 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. 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
6-0m-pa-n-y- .......... -------T. Location where contents were disposed:
Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780
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08/29/2025
Signature of Hauler Dace
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nature of Receiving Facility(or attach facility receipt) Date
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