1 DIPIETRO AVENUE SYSTEM PUMPING RECORD 12-28-22 RECEIVED
Commonwealth of Massachusetts JAN 2 6 2023
y City/1-own Of Salem
System Pumping Record CITY OF
'� •�,' y p g BOARD OF HEALTH
Form 4
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:
1 Dipietro Avenue.,_
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Susan Sp i na i e - -- ------------- -- ---
Name
1 Dipietro Avenue,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
6177210395 x
Telephone Number
B. Pumping Record
1. Date of Pumping 12/28/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank R Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes, was it cleaned? 0 Yes No
5. Observed condition of component pumped:
S to r gpe.r.a-t�nn Fs-�n�..-nrarural wa it-e-uel-Modem-rate t op-solids_.---Madexate battora-
tank; current tankis not designed to be used with a filter. Cover(s) secure -.
Pumped 1000 gallons. Recommended No Recommendation.
6. System Pumped By:
Marcus Lark
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
r'I" 12/28/2022
!i1
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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