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144 CANAL STREET SYSTEM PUMPING RECORD 8-26-25Commonwealth 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 144 Canal Street MA 01970 Starbucks 85 Wells Avenue, Suite 110 02459Newton Center 4133274959 MA 08/26/2025 2000.0000 Cover was accessed and properly secured. Grease Tank system serviced. Filter not present. Tank cannot be outfitted with filter. 2000 gallons removed. 8 inches of bottom sludge. 8 inches of grease on top. 25 inches of water. System is at proper working level. Both baffles/tees are intact. Main line is clear. Jaime Rivera NENO Yard: 163 Western Ave, Gloucester, MA 01930 08/26/2025 Salem Salem Jaime Rivera 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 23 Grove Street MA 01970 Robert Mcmanus 23 Grove Street 01970Salem 9788808734 MA 08/28/2025 1000.0000 Cover was accessed and properly secured. Cesspool system serviced. Filter not present. Tank cannot be outfitted with filter. 500 gallons removed. Moderate sludge on bottom of tank. Light top solids in tank. System is at proper working level. Main line is clear. Recommend using boost next pumping. Adding treatment between now and then will improve the health of your system. Please visit www.bookmyseptic.com to purchase online. Robert Herrick NENO Yard: 163 Western Ave, Gloucester, MA 01930 08/28/2025 Salem Salem Robert Herrick 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 08/07/2025 100.0000 Basement. 2 inches of grease on top. 12 inches of water. 2 inches of bottom sludge. 40 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. Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/07/2025 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 15 Bridge Street MA 01970 Ninety Nine Restaurant 14A Gill Street 01801Woburn 6172428999 MA 08/07/2025 100.0000 3 Bay Sink. 2 inches of grease on top. 14 inches of water. 2 inches of bottom sludge. 50 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. Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/07/2025 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 7 Traders Way MA 01970 Londi's Famous Roast Beef 7 Traders Way, 01970Salem 9787411100 x MA 08/21/2025 100.0000 Back Room. 4 inches of grease on top. 4 inches of water. 4 inches of bottom sludge. 35 gallons removed. Both baffles/tees are intact. Gasket is in bad condition - Recommend replacing gasket. Grease trap needs 1 bolt replaced. Walls/bottom of trap in good condition. System is at proper working level. Left 0 bottles of drain master. BOH Logs Signed. Gasket and bolt. Josh Melendy Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/21/2025 Salem Salem Josh 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 9 Bridge Street MA 01970 Bill & Bob's Restaurant 9 Bridge Street, 01970Salem 9787449835 x MA 08/07/2025 20.0000 3 Bay Sink. 4 inches of grease on top. 6 inches of water. 4 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. Silicone applied to trap cover. Left 0 bottles of drain master. BOH Logs Signed. Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/07/2025 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 144 Canal Street MA 01970 Starbucks 85 Wells Avenue, Suite 110 02459Newton Center 4133274959 MA 08/11/2025 100.0000 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. Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/11/2025 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 7 Traders Way MA 01970 Londi's Famous Roast Beef 7 Traders Way, 01970Salem 9787411100 x MA 08/07/2025 100.0000 3 Bay Sink. 4 inches of grease on top. 8 inches of water. 4 inches of bottom sludge. 40 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. Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/07/2025 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 08/21/2025 20.0000 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. Recommend Drain Cleaning. Gasket and bolt. Josh Melendy Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/21/2025 Salem Salem Josh 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 282 Derby Street MA 01970 All Souls Lounge 282 Derby Street 01970Salem 9783951517 MA 08/07/2025 100.0000 3 Bay Sink. 4 inches of grease on top. 8 inches of water. 4 inches of bottom sludge. 40 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. Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/07/2025 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 31 Bridge Street MA 01970 Dunkin Donuts - Fabios Donuts 241 Maple St 01949Middleton 9785781124 MA 08/07/2025 100.0000 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. Outlet baffle was clogged up causing trap to start overflowing when draining the sink, unclogged baffle and tested water flow, everything working properly again. BOH Logs Signed. Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/07/2025 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 282 Derby Street MA 01970 Sweet Boba 1032 Great Plain, 02492Needham 7818546253 x MA 08/07/2025 100.0000 Kitchen. 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. Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/07/2025 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 1 Kernwood Street MA 01970 Kernwood Country Club 1 Kernwood Street 01970Salem 9787451210 MA 08/07/2025 200.0000 3 Bay Sink. 2 inches of grease on top. 12 inches of water. 2 inches of bottom sludge. 40 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. Kitchen. 1 inches of grease on top. 12 inches of water. 1 inches of bottom sludge. 30 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/07/2025 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 1 Kernwood Street MA 01970 Kernwood Country Club 1 Kernwood Street 01970Salem 9787451210 MA 08/21/2025 200.0000 Kitchen. 4 inches of grease on top. 4 inches of water. 4 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. 3 Bay Sink. 3 inches of grease on top. 6 inches of water. 3 inches of bottom sludge. 32 gallons removed. Both baffles/tees are intact. Gasket is in good condition. Walls/bottom of trap in good condition. Josh Melendy Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/21/2025 Salem Salem Josh 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 Howling Wolf Taqueria 76 Lafayette Street 01970Salem 6179918398 MA 08/11/2025 100.0000 3 Bay Sink. 6 inches of grease on top. 6 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. 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. Trap is being replaced. BOH Logs Signed. Recommend Inside Grease Trap Replacement. Trap is being Steven Dominguez Water Solutions Group: 35 Mozzone Blvd , Taunton, MA 02780 08/11/2025 Salem Salem