15 BRIDGE STREET SYSTEM PUMPING RECORD 12-7-22 INN Commonwealth of Massachusetts RECEIVED
City/Town of Salem JAN 2 6 2023
:Y System Pumping Record
Form 4 CITY OF SALEM
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:
15 Bridge Street
Address
Salem _ MA 01970
City/Town State _ Zip Code
2. System Owner:
Ninety Nine Restaurant
Name
14A Gill Street
Address(if different from location)
Woburn MA 01801
City/Town State Zip Code
7819325163 x
Telephone Number
B. Pumping Record
1. Date of Pumping 12/07/2022 2. Quantity Pumped: 2000.0000
Date Gallons
3. Component: ❑ Cesspool(s) septic Tank F1 Tight Tank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑X No If yes, was it cleaned? F Yes ❑ No
5. Observed condition of component pumped:
-No-r-ma-L-water-1veL.r 2-ire-fie _tam- -ludg�� r�-t--gyp-.-solids Bo-th-baf -_are ixitort
�d with a filter. Cover(s) secured. No r party paperwork filled.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
South essex sewerage district: 50 Fort Ave, Po Box 989, Salem MA 01970
f.
_ _ 12/07/2022.
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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