10 CEDARVIEW STREET SYSTEM PUMPING RECORDS 05/08/2013 13:32 9782814869 WINDRIVER PAGE 07/07
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commonwealth of Massachusetts Form 4--System Pumping Record 26M
Massachusetts
System Pumping Record
System Owner System Location
Dixon Roberti Primary Bome
10 Cedarview 5trGGt 10 Cedarview ate:eet
Salem, t?S, 01970 Salem, MA, 01.9 0
(978)-744-5700 x (97Pr)-744-5700 x
Dixon Robert
Type: ;EmergenRoutine
cesspool: No ^ Yes Septic Tank: No Yes��
Date of Pumping: Quantity Pumped'6V Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: I.W.W.Im
�(- -� 3 f
Date: 17
� Pumper5ignature: ��•
Condition of System/Other Comments �✓
r
�� PnmtJpnrtrydcdpnpsr Dep Approved Form-12/07/95
- fk:�L37(i"iE1t-ei(1 o3n.712oDs
Commonwealth of Massachusetts Form 4—system Pumping Record x260%
Massachusetts
System Pumping Record
SySTem Owner System Location
Dixon Robert Primary Home
10 Cedarview Street 10 Cedarview Street
Salem, MA, 01970 Salem, MA, 01970
(978)-744-5700 x (978)-744-5700 x
Dixon Robert
pype: Emerge Routine
:esspool: No yes Septic Tank: No Yes®
)ate of Pumping: — I�- Quantity Pumped: I'M 0 Gallons
System Pumped 6y: Wind River Environmental,LLC Permit#:
contents Transferred to:
Contents Disposed at:
&EAD
Date:
Pumper signature:
Condition of System/Other Comments
5p°
d
'rr1 C C
Dep Approved Form-12/07/95
70/40 39174 d3AIJONIM 6987TKK6 TO:TT LTOL/TT/70
Commonwealth of Massachusetts
City/Town of Salem ®�
System Pumping Record eo rry l 11p0F®
b` Form 4 ��
hq�FM
DEP has provided this form for use by local Boards of Health. Other forms may be ut 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
Important:
When filling out 1. System Location:
forms on the
computer,use12-Ceder iew
only the tab key Address
to move your Salem MA 01970
cursor-do not Cit !town
use the return y State Zip Code
key. 2. System Owner:
VQ Francis Gadenne
Name
Address(if different from location)
Citylrown State Zip Cade
978-744-3892
Telephone Number
B. Pumping Record
1. Date of Pumping Date/11 2, Quantity Pumped: 1500
Gallons
3. Type of system: ❑ 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. Condition of System:
Good condition.
6. System Pumped By:
Dustin Prieur K84568
Name Vehicle License Number
PSAD LLC
Company
7. Location where contents were disposed:
� /_,
Ipswich waste water treatment lant.
7/19/11
( 1 ,
'Sgnature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
O'1t220aG33t 03/27/2009
Commonwealth of Massachusetts Form 4--System Pumping RecorclM
Massachusetts
System Pumping Record
System Owner System Location
Dixon Robert Primary Bone
10 Cedarview Street 10 Cedarview Street
Salem, MA, 01970 Salem, MA, 01970
(978)-744-5700 x (978)-744-5700 x
,Dixon Robert
Type: EmergencRoutine
• a .
Cesspool: No ,O Yes Septic Tank: No Yes®>
Date of Pumping: ...� �t Quantity Pumped: OD Gallons '
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
a
ECE"'VED
If
:.-V 0 42o"
(:0-Y OF SALEM
BUAND OF HEALTH
® Pn,,,cdonn,gdedpiper Dep Approved Form-12/07/95
L
i
i r "66222d29877 03127/2000
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System,Ownev P System Location
Dixon Robert Primary Home
lu cedarview Street 10 Cedarv.iew Street
Salem, Mn, 0191V Salem, MA, u1970
yrnr raa- ruu x x
Hixon Robert
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: I25 Quantity Pumped:.() Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
i
Contents Transferred to:
Contents Disposed at: S.E.S.D.
Salem, MA.
Date: Pumper Signature:
Condition of System/Other Comments
IIS
s
Dep Approved Form-12/07/95