3A WINTER ISLAND ROAD SYSTEM PUMPING RECORD 11-16-22 RECEIVE®
< Commonwealth of Massachusetts
! City/Town Of
DEC 0 8 2022
,._ Salem
u CITY OF SALEM
System Pumping Record Form 4 BOARD OF HEALTH
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:
3A Winter Island Rd
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Winter Island Yacht Yard
Name
3A Winter Island Road,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787453797 x
Telephone Number
B. Pumping Record
1. Date of Pumping 11/16/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank R Tight Tank ❑Grease Trap
7 Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑X No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
Not Applicable water level nln ]Dottarn sliadge 0 i n top solids Main line Net
used with a filter. No . rd party paperwork filled.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlboroue[h, MA 01752
Company
7. Location where contents were disposed:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
11/16/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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