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15 BRIDGE STREET SYSTEM PUMPING RECORD 3-13-25Commonwealth 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 15 Bridge Street MA 01970 Ninety Nine Restaurant 14A Gill Street 01801Woburn 9783728303 MA 03/13/2025 2000.0000 Cover was accessed and properly secured. Grease Tank system serviced. Filter not present. Tank cannot be outfitted with filter. 2000 gallons removed. 3 inches of bottom sludge. 2 inches of grease on top. 40 inches of water. System is at proper working level. Both baffles/tees are intact. Main line is clear. Michael Graham South essex sewerage district: 50 Fort Ave, Po Box 989, Salem , MA 01970 03/13/2025 Salem Salem Michael Graham Commonwealth 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 14 Cedar View Street MA 01970 Grace Lamarre 14 Cedar View Street 01970Salem 4127205965 MA 03/10/2025 1500.0000 Cover was accessed and properly secured. Septic system serviced. Filter not present. Tank cannot be outfitted with filter. 1500 gallons removed. Light sludge on bottom of tank. Moderate amount of top solids in tank. System is at proper working level. Both baffles/tees are intact. Main line is clear. Recommend adding Treatment. Please visit www.bookmyseptic.com to purchase online. Marcus Lark HaverHill Disposal Site: 40 S. Porter Street, Bradford, MA 01835 03/10/2025 Salem Salem Marcus Lark Commonwealth 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 Dipietro Avenue, MA 01970 Susan Spinale 1 Dipietro Avenue, 01970Salem 6177210395 MA 03/11/2025 1000.0000 Cover was accessed and properly secured. Tight Tank system serviced. Filter not present. Tank cannot be outfitted with filter. 1000 gallons removed. Light sludge on bottom of tank. Light top solids in tank. System is at proper working level. Unable to test main line. Jonathon Colson NENO Yard: 163 Western Ave, Gloucester, MA 01930 03/11/2025 Salem Salem Jonathon Colson Commonwealth 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 7 Traders Way MA 01970 Londi's Famous Roast Beef 7 Traders Way, 01970Salem 9787411100 x MA 03/06/2025 100.0000 Cover was accessed and properly secured. 3 Bay Sink. 4 inches of grease on top. 8 inches of water. 4 inches of bottom sludge. 30 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. BOH Logs Signed. Joao Varela Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/06/2025 Salem Salem Francisco Barros Commonwealth 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 9 Bridge Street MA 01970 Bill & Bob's Restaurant 9 Bridge Street, 01970Salem 9787449835 x MA 03/06/2025 20.0000 Cover was accessed and properly secured. 3 Bay Sink. 4 inches of grease on top. 6 inches of water. 4 inches of bottom sludge. 30 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. BOH Logs Signed. Joao Varela Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/06/2025 Salem Salem Francisco Barros Commonwealth 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 83 Washington Street MA 01970 The Juicery 40 State Street 01950Newburyport 6032341223 MA 03/06/2025 100.0000 Cover was accessed and properly secured. Basement. 2 inches of grease on top. 6 inches of water. 2 inches of bottom sludge. 30 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. BOH Logs Signed. Joao Varela Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/06/2025 Salem Salem Francisco Barros Commonwealth 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 125 Canal Street MA 01970 Crosby's Market Inc. 125 Canal Street, 01970Salem 9787454272 x MA 03/26/2025 200.0000 Cover was accessed and properly secured. Bakery. 2 inches of grease on top. 6 inches of water. 4 inches of bottom sludge. 30 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. Meat. 2 inches of grease on top. 6 inches of water. 2 inches of bottom sludge. 20 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom Joao Varela Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/26/2025 Salem Salem Francisco Barros Commonwealth 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 144 Canal Street MA 01970 Starbucks 85 Wells Avenue, Suite 110 02459Newton Center 4133274959 MA 03/24/2025 100.0000 3 Bay Sink. 2 inches of grease on top. 6 inches of water. 3 inches of bottom sludge. 25 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Grease trap needs 1 bolt replaced. Walls/bottom of trap in good condition. System is at proper working level. Silicone applied to trap cover. Left 0 bottles of drain master. Recommend Drain Cleaning. DC PM jetting. DC to replace 1 bolt. BOH Logs Signed. Jay Beaudoin Holbrook WRE Yard: 24 South Street, Holbrook, MA 02343 03/24/2025 Salem Salem Jay Beaudoin Commonwealth 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 7 Traders Way MA 01970 Londi's Famous Roast Beef 7 Traders Way, 01970Salem 9787411100 x MA 03/20/2025 100.0000 Back Room. 2 inches of grease on top. 10 inches of water. 2 inches of bottom sludge. 38 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. BOH Logs Signed. IG Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/20/2025 Salem Salem Commonwealth 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 9 Bridge Street MA 01970 Bill & Bob's Restaurant 9 Bridge Street, 01970Salem 9787449835 x MA 03/20/2025 20.0000 3 Bay Sink. 2 inches of grease on top. 10 inches of water. 2 inches of bottom sludge. 30 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. BOH Logs Signed. IG Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/20/2025 Salem Salem Commonwealth 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 211 Washington Street MA 01970 Starbucks 85 Wells Avenue, Suite 110 02459Newton Center 4133274959 MA 03/25/2025 100.0000 3 Bay Sink. 3 inches of grease on top. 12 inches of water. 3 inches of bottom sludge. 25 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. BOH Logs Signed. Marvin Collado Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/25/2025 Salem Salem Marvin Collado Commonwealth 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 177 Fort Avenue MA 01970 Sage's Fusion Kitchen 177 Fort Avenue 01970Salem 6175197388 MA 03/14/2025 0.0000 NO ACCESS Joshua Melendy 03/14/2025 Salem Salem Joshua Melendy Commonwealth 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 45 Congress Street, Building 4, Suite 160 Shetland Park, MA 01970 Gillian's Foods 45 Congress Street, building 4 Suite 160 01970Salem 3512016281 x MA 03/06/2025 200.0000 Basement. 6 inches of grease on top. 24 inches of water. 4 inches of bottom sludge. 200 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. Basement. 8 inches of grease on top. 20 inches of water. 6 inches of bottom sludge. 200 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. Joao Varela Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/06/2025 Salem Salem Francisco Barros Commonwealth 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 45 Mason Street MA 01970 Holy Cow Ice Cream Cafe 80 Pleasant Street 01930Gloucester 7819104195 MA 03/14/2025 100.0000 3 Bay Sink. 3 inches of grease on top. 6 inches of water. 3 inches of bottom sludge. 35 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. BOH Logs Signed. Joshua Melendy Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/14/2025 Salem Salem Joshua Melendy Commonwealth 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 181 Fort Avenue MA 01970 Holy Cow Ice Cream Cafe 80 Pleasant Street 01930Gloucester 7819104195 MA 03/14/2025 0.0000 NO ACCESS Joshua Melendy 03/14/2025 Salem Salem Joshua Melendy Commonwealth 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 76 Lafayette Street MA 01970 JAA Services 10 Fort Eddy Road 03301Concord 6179918398 NH 03/14/2025 100.0000 There is a safety concern onsite that needs immediate follow up!. 3 Bay Sink. 6 inches of grease on top. 2 inches of water. 6 inches of bottom sludge. 50 gallons removed. Both baffle/tees are not intact. Recommend inlet/outlet repair. Gasket is in bad condition - Recommend replacing gasket. Grease trap needs 1 bolt replaced. Walls/bottom of trap are in need of repair. Recommend Trap Repair/Replace. System is at proper working level. Left 0 bottles of drain master. Recommend New Cover. Joshua Melendy Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 03/14/2025 Salem Salem Joshua Melendy