11 VINNIN STREET SYSTEM PUMPING RECORD 10-29-24 RECEIVED
N Commonwealth of Massachusetts
City/Town of Salem DEC 0 4,2024
W7 '-
System Pumping Record CITY OFSALEM
i Form 4 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:
11 Vinnin Street, _
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Therapy for Intentional_ Living Inc
Name
50 Jersey Street,
Address(if different from location)
Marblehead MA 01945
City/Town State Zip Code
7817324161 x
Telephone Number
B. Pumping Record
10/29/2024 1000.0000
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 ❑X No If yes,was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
Cover was accessed and properly secured. Cesspool system serviced. Filter not
present. Tank cannot be outfitted with filter. 1000 gallons removed. 6 inches of
bottom sludge. 4 inches of top solids. System is at proper working level. Both
baffles/tees are intact. Main line is clear. Recommend using boost next pumping.
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:
Gloucester WPCF: 50 Essex Avenue, Gloucester, MA 01930
Michael Graham 10/29/2024
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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