266 CANAL STREET SYSTEM PUMPING RECORD 11-7-23Commonwealth 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
266 Canal Street
MA 01970
JDC Demo Inc
115 4th Avenue
02494Needham Heights
7742973880
MA
11/07/2023 1000.0000
Not Applicable water level. 0in bottom sludge. 0in top solids. Main line Not
Applicable . No filter is present on the tank; current tank is not designed to be
used with a filter. No 3rd party paperwork filled. Cover is off with ASAP draing
cleaning on site.
Robert Herrick
NENO Yard: 163 Western Ave, Gloucester, MA 01930
11/07/2023
Salem
Salem