6 PETER ROAD SYSTEM PUMPING RECORD 5-11-23Commonwealth of Massachusetts
City/Town of
System Pumping Record
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.
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1
A.Facility Information
1.System Location:
Address
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:Gallons
3. Component: Cesspool(s) Septic Tank Tight Tank Grease Trap
Other (describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
6 Peter Road,
MA 01970
Maria Kouris,
6 Peter Road,
01970Salem
6178996542 x
MA
05/11/2023 1000.0000
System Operating Fine. Normal water level. Moderate top solids. Moderate bottom
sludge. Both baffles are intact. Main line Clear. No filter is present on the
tank; current tank is not designed to be used with a filter. Cover(s) secured.
Removed 1,000 gallons one chamber tank. 3 hoses required to complete this job from
the curb. No filter present tank is not designed to be used with one. Cap is
located behind the house 10 in below grade underneath the bird bath . Top solids
heavy bottom sludge light. Recommend boost combination 1,000 gallons. Customer
declined bacteria. Recommended Boost additive,Wind River Septic System Treatment
additive.
Ronnie Soucie III
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA 01845
05/11/2023
Salem
Salem