1 PETER ROAD SYSTEM PUMPING RECORD 12-21-23Commonwealth 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
1 Peter Road
MA 01970
Pamela O'Donnell
1 Peter Road
01970Salem
6178776125
MA
12/21/2023 1500.0000
System Operating Fine. Normal water level. Moderate top solids. Moderate bottom
sludge. Both baffles are intact. Main line Clear. Filter is present and has been
cleaned as needed. Cover(s) secured. Recommended No Recommendation. Recommend
using boost next pumping. Adding treatment between now and then will improve the
health of your system. Please visit https://portal.wrenvironmental.com/ to
purchase online.
Robert Herrick
NENO Yard: 163 Western Ave, Gloucester, MA 01930
12/21/2023
Salem
Salem
Robert Herrick