23 GLENDALE STREET SYSTEM PUMPING RECORD 12-6-22 Commonwealth of Massachusetts RECEIVE®
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City/Town of Salem JAN 2 6 2023
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:
23 Glendale Street,
Address
Salem MA 01970
City/Town State Code __
2. System Owner:
The Fred J Dion Yacht Yard
Name
23 Glendale Street _
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787676201 x
Telephone Number
B. Pumping Record
1. Date of Pumping 12/06/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) Q Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑X No If yes, was it cleaned? 0 Yes ❑ No
5. Observed condition of component pumped:±6 PLe5ellt 011 tht:� tank; cu-LzeiiL Lank ±s not designed to be used w±tl a fttter.
Cover s secured. No Tndparty paperwork filled.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
12/06/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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