System pumping records 1999-2017 RECEIVED 06/16/2017 04:59PM 9787450343 Salem Health Dept
06/16/2017 16:52 9782814869 WINDRIVER PAGE 04/05
:� Commonwealth of Massachusetts
U
City/Town of R-vvw,_
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.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, / �_ ^-��7
use only the tab �/Y__// /�6L
key to move your Address
cursor•do not QMA
key y me return City/Town State Zip Code
` I
2. Syste ner.
G kt
Name —
Address(if different from location)
City/Town Slate, Code
Telephone Number , 7
B. Pumping Record �-
1, Date of Pumping
Date �2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) I
$optic Tank ❑ Tight Tank ❑ Grease Trap
❑
Other(describe): --,--
4. Effluent Tee Filter present? ❑ Ye F1 No If yes, was it cleaned? F] Yes ❑ No
5. Observed condiof comp n, um
ti mped:
6. System Pu ped XU�j
Name t Vehicle Li ansa Number
Wind River Envidt16666n Wind River Environmental
Company Bradford, OWS 163 Western Ave.
7. Location where is of Gloucester,MA 01930
_-eSignature of Hau � Date
Signature of Receiving Facility(or attach facility moeipt) Oate m
t5form4.docc 11/12 System Pumping Record•Page 1 of 7
RECEIVED 07/27/2016 11:40AM 9787450343 Salem Health Dept
07/27/2016 11:35 9782814869 WINDRIVER PAGE 03/06
0207073235 n:,�at�zaoo
Commonwealth of Massachusetts Form a--System Pumping Record 61F71Y.
Massachusetts w
System Pumping Record
System Owner System Location
Lachapellle Richard Primary Some
334 Highland kienue 334 Highland Avenue
Salem, lAA, 01970 Salem, MAI 01970
(979)-741-5076 x (978)-744-5016 x
Lachapelle Alda
Type: Emerge Routine \/'
Cesspool: No V yes Septic Tank: No yes g—
Date of Pumping: 0 15– L b l quantity Pumped: lCr'C� Gallons
System Pumped By: Wind River Environmental,LLC Permit 7f:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
LW
Psw.Ck MA.
ch;m ao„mcy�icdonar Dep Approved Form-12/07/95
07!18!2013 11:42 9782814869WINDRIVER PGGE 01/08
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Commonwealth of Massachusetts Form 4—System Pumping Record,
Massachusetts
System Pumping Record
I
!*stem Owner System Location
mAchapelle Ada Primary Home
334 Highland Ave 3.34 Highland Ave
Salem, 14A, 01970 Salem, MA, 07.970
(978)-744-5075 x 1978}-744-5076 x
achapelle Aida
Type: Emergenc� Routine
Cesspool: No yes Septic Tank: No Y,J�
Date of Pumping: IO.— Quantity Pumped: i/04VO Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
'Contents Transferred to:
Contents Disposed at:
bate: Pumper Signature:
Condition of System/Other Comments
FN VINO ry;-MIT
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Drain Problems? We're Local$Fast
1-866.866-6214
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0207030366 tx �
commonwealth of Massachusetts Form 4•-System Pumping Record
Massachusetts
System Pumping Record
iystem Owner 5ystem Location
Lachapelle Alda Primary 11011e
335 Highland Ave 333 Highland Ave
Salem, MA, 01970 Salem, MA, 01910
(978)-744-5076 x (978)-744-5076 x
Lachapelle Alda
We: Emergen Routine
:esspool: No oc Yes Septic lank: No Yes
)ate of Pumping: (/O- Quantity Pumped: /D00 Gallons
iystem pumped By: Wind River Environmental,LLC Permit#:
.ontenTs Transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of system/Other Comments
C7
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.r. Dep Approved Form-12/07/95
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Commonwealth of Massachusetts Form 4--System Pumping Recordp%
r . ,oti Massachusetts
System Pumping Record
System Owner System Location
Lachapelle Alda Primary Home
334 Highland Ave 334 highland Ave
Salem, MA, 01970 Salem, MA, 01970
(97B)-744-5076 x (978)-744-5076 x.
Lachapelle Alda
Type: Emergent Routine
Cesspool: No Yu Septic Tank: No = Yesl
Date of Pumping: Quantity Pumped:1 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
RECEIVED
MAX 942011
CITY OF SALEM
BOARD OF HEALTH
® Mm,d.n,eq&dpapa Dep Approved Form-12/07/95
W—
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Lachapelle Alda Primary Home
334 Highland Ave 334 Hiqhland Ave
Helens, NIA, 019.70 Salem, MA, 019'10
(978)-744-5076 x (9'78)-744-5076 x
Lachapeile Alda
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: a — ) D Quantity Pumped: /Ot Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
S.E.S.D.
Salem, MA,
Date: Pumper Signature:
Condition of System/Other Comments
�pR_9`1010 ,cN
Dep Approved Form-12/07/95
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Type: Emergency Routine 1
Cesspool: No Yes Septic Tank: NoYesl`
Date of Pumping: >, 0C Quantity Pumped: / Gallons
System Pumped By: Wind River Environmental,LLC - Permit#:
Contents Transferred to:
Contents Disposed at:
S.E.S,D.
, .
Date: Pumper Signature:
I
{ Condition of System/Other Comments
Dep Approved Form-12/07/95
EGET ED
APR 0 6 2009
Gi OF S,j1_EM
^)AF-10 OF HEALTH
Farm 4 -- System Pumping Record
Commonwealth of Massachusetss
Massachusetts
System Pumoim Record
System Owner System Location
Lachapelle Alda primary Home
334 Highland Ave 334 Highland Fare
Salam, MA, 67.970 Salenl, MA, 01470
(0601 . 744-5076 a (000) -744-5076 u,
Type: Emergency Routine ✓
Cesspool: No (/ Yes Septic tank: Plo Yes E
Oats of Pumping: Q Quantity Pumped: . , Salon
System Pumped By: Wmd Rirrr Enwwa ental, [LC Permit#:
Contents transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
�u
MAY'5 - 2004
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Foran - 12/07/95
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0222020635,' 0510112000
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
Y P 9
System Owner _ System Location
Lachapelle Alda Primary Home
334 Highland Ave 334 Highland Ave
Sahni, MA, 01970 Salem, MA, 01970
{9781-744-5076 x J (976)-744-5076 x
Lachapelle Alda
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: 2,— -0 Quantity Pumped: /Opt) Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: SO
Date: 3 -2 �-O E) Pumper Signature:
Condition of System/Other Comments
RECEIVED
ADR —4 2008
CITY OF SALEM
Dep Approved Form-12/07/95
2
1
FORM 4-SYSTEM PUMPING RFCCOPDD
CURRIE RD �(CEAIVED
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON,MA 01949
(978)774-2772 O C i 4 - 1999
CITY OF SALEM
HEALTH DEPT.
CMMONWEALTH OF MASSACHUSETTS
x�em MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER: 1�C �rj e P SYSTEM LOCATION:
DATE OF PUMPING: c7` 3 - g 9 QUANTITY PUMPED: GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: S �F-73-D
DATE: �_3 ' �� - INSPECTOR:-6m(2 .f