HomeMy WebLinkAboutPanera Bread Grease Trap - Septic Pumping Slip - 58 PETERS STREET 8/24/2026 Town of North Andover
Commonwealth of Massachusetts
City/TownOf North Andover
SEP 2 2026
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,1;WQUbrrQ&PaftMent
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:
58 Peters Street
Address
North Andover MA 01845
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2. System Owner:
PR Restaurants LLC Panera Bread IG Panera Bread #3410
.............
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
08/24/2026 100.0000
1. Date of Pumping - 2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) [-I Septic Tank F-]Tight Tank Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? R Yes nX No If yes, was it cleaned? ❑Yes R No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Left 0 bottles of drain master. System is at proper
working level. Walls/bottom of trap in good condition. Gasket is in good condition. Both
baffles/tees are intact. 50 gallons removed. 4 inches of bottom sludge. 6 inches of water. 4
inches of grease on top. FOG 57%. 3 Bay Sink. BOH Logs Signed.
6. System Pumped By:
Kylen Grace
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborou h, MA 01752
Company-
7. Location where contents were disposed:
Inside Grease - NEMO Yard: 54 Knox Trail, Acton, MA 01720
Kylen Grace 08/24/2026
Signature of-Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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