System Pumping Records (004) RECEIVED 07/28/2017 03:48PM 9787450343 Salem Health Dept
07/28/2017 15:40 9782814869 WINDRIVER PAGE 01/05
Commonwealth of Massachusetts
City/Town of `evv,
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, LIC)C, L
use only the tab T`G,y T7c- Jl _ _, -----�_•
key to move your Addres
cursor-do not
G1 MA -Ci C
use the return
key, Citylrown state Zip Code
2. ystem Owner:
Name �-
ream
Address(if different from location) 7
CnylTown state Zip coda
(i, 9` 7-S - �C�Jp — e'4 6 7-
Telephone Number
B. Pumping Record
0
1. Date of Pumping ata 2 � 2. Quantity Pumped: Gallons -
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes f25\No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
CL
6. System Pumped By:
Name Vehicle license Number
Wind River Environmental
Company
STEWARTS SEPTIC SERVICE
7. Location where contents were disposed:
58 SOUTH KIMBALL ST.
-----$RADFORD,MA-07835 ---.
978-372-7471
Signature of Hauler Date - ~
Signature of Receiving Facility(or attaeh facility receipt) Date
t5fonma,doc-11112 System Pumping Record-Page 1 of 1
RECEIVED 07/27/2016 11:40AM 9787450343 Salem Health Dept
07/27/2016 11:35 9782814869 WINDRIVER PAGE 02/06
N, 0207072807 a5.o7rz000
Commonwealth of Massachusetts Form 4--system Pumping Record 6,='A
Massachusetts
System Pumping Record
System Owner System Location
7{irkpa.trick Peter Primary nome
409 Lafalre'tte Street 409 Lafayette Street
Salem, MA, 07.970 Salem, MA, 01970
(9'78)-741-2407 x f979)-741-2407 x
Rirkpatrick Peter;
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: /�(A �/ Quantity Pumped: /5Z>C>Gallons
System Pumped 8y: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: .
)ote: Pumper Signature:
"onditlon of 5ystem/Other Comments
Haverhill -
An 6 1"e4er d$
Fir rfs,rC9, Bela 01335
(973) 374-2382
Mn�naneeeyekdprym Dep Approved Form-12/07/95
06/22;2015 23:52 9782814869 WINDRIVER PAGE 07/09
p510if2ppQ
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Looation
Ai;kpratr'ick Peter ro
_rzmary Home
409 Lafayette Stree,; 409 Lafayette Stcar;
Sa1Em, PA, 015i70 galr�ni, , 01970
(9i8).-741-2407 x (978; -711-2407 x
Fir)cP.atrick peter.
Type: Emerg¢n Routine
Septic Tank: No Yes
Cesspool: No Z7 Yes
Date of Pumping:
Quantity Pumped: Lallans
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to: ..
^" •S.:ontents Disposed at: SW �/•
em, MA.
)ate: Pumper Signature: 1 --
:ondition of System/Other Comments
Primca o.,mma�, . Dep Approved Form-92/07/95 j/
03/05/2014 10:16 9782814869 WINDRIVER PAGE 03/05
Commonwealth of Massachusetts Form 4—5ystem Pumping RecordST,
Massachusetts
System Pumping Record
Sy d 0 n' •� System Location
Kirkpatrick Peter Primary SDM6a
409 'Lafayette St 409 Lafayette St
Salem, MA, 01970 Salem, MA, 01970
(978)-741-2407 x (978)-741-2407 x
Rickpatri.ck Peter
Type: Emergent Routine C
Cesspool: No Yes L� Septic Tank: No YesF
Date of Pumping; I Quantity Pumped: /OO G Gallons
.5ystem Pumped By: Wind River Environmental,LLC Permit#:
ebntents Transferred to; .
ContentsDisposed at:
S.E.S.D.
Date: Pumper Signature:
Condition of 5ystem/Other Comments
..._._—.�—.—.�Dep AppravedForm T12/07/95
05/08/2013 13:32 9782814869 WINDRIVER PAGE 02107
rIG<n.MM1fIn
Y }• ww..�-�..nn.�
Commonwealth of Massachusetts Form 4--system Pumping Record i_iW%
Massachusetts
System Pumping Record
Sys F/ne System Location
Kirkpatrick Peter Primary Home
409 Lafayette St 409 Lafayette St
Salem, MA, 01910 Salem, MA, 01970
(978)-741-2407 x (978)-741-2407 x
Kirkpatrick Peter
Type: Emergen Routine
Cesspoal: No Yes Septic Tank: No Yes
Date of Pumping: l — G Quantity Pumped: Gallons
system Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
1.w.w.T.P.
Ipswich; MA.
Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved Form•12/07/95
Commonwealth of Massachusetts Form 4--System Pumping Record i0%
Massachusetts
System Pumping Record
System Owner System Location
Kirkpatrick Peter Primary Home
409 Lafayette St 409 Lafayette St
Salem, MA, 01970 Salem, MA, 01970
(978)-741-2407 x (978)-741-2407 x
Kirkpatrick Peter
Type: Emergenc Routine
Cesspool: No Yes Septic Tank: No F-1 Yes
Date of Pumping: Quantity Pumped:_Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
S.E.S.®.
Salu%m MA.
Date: Pumper Signature:
Condition of System/Other Comments
mv;r �
3 2p11
CITY OF SALEM
® Primedonm ydedpN, Dep Approved Form-12/07/95
r _ .___. ___..___. ...
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
s0UI1bW`&r-" l—v g` N P"I gook Yalu n System Location
Kirkpatrick Peter Primary Home i
409 Lafayette St 409 Lafayette St /
Salem, MA, 01970 Salem, MA, 01970
(978)-741-2407 x (978) ''74a1ZA07
Kirkpatrick peter
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No_� Yes
Date of Pumping: j-�y `j 5 Quantity Pumped: /.i O Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: cC n
s.F-.q n-
MV MA.
Date: - 4-c) S Pumper Signature: `� ^
Condition of System/Other Comments
,
"Dr
CQ0z
Dep Approved Form-12/07/95
i
n�nn+aa�a nvninr�nn
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record n
!J
S
System Owner stem Location
Y Y
Kirkpatrick Peter Primary RM- 0
409 Lafayette St 409 Lafayette St
Salem, MA, 01970 Salem, MA, 01970
(978)-747.-2407 x (978)-741-2407 x
Kirkpatrick Peter
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: 1�g.�Q Quantity Pumped: Gallons
System Pumped By: I Wind River Environmental,LLC Permit#:
Contents Transferred to:
e
Contents Disposed at: S.E.S,D,
Salem, MA.
I
Date: Pumper Signature: /
Condition of System/Other Comments
RECEIVED
I
FEB 112008
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Form-12/07/95
FORM 4- SYSTEM PUMPING RECORD
CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772 NOV t 5 2000
CITY OF SALEM
HEALTH DEPT.
COMMON VEALTH OF MASSACHUSETTS
MASSACHUSETTS
SY
STEMPUMPIN
G RECORD
SYSTEM OWNER: SYSTEM LOCATION:
�I a
DATE OF PUMPING:
QUANTITY PUMPED: �� S
CESSPOOL: NO YES ❑ SEPTIC TANK: NO /ES `
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
o,
DATE: ( LL-Lo INSPECTOR:
t
ER FORM 4-SYSTEM PUMPING RECORD
cL :'
SEPTIC & DRAIN SERVICE -
107 FOREST STREET;h6DLETON,MA 01049 '
(978)774-2772
SAVED
COMMONWEALTH OF MASSACHUSETTS FOCI '- 1998
9 .
MASSACHUSETTS
NEA�H DEPT.
SYSTEM PUMPING RECORD
SYSTEM OWNER: Y/ JCSYSTEM LOCATION:
Sa lerYl 7liO �rrq&�
DATE OF PUMPING: QUANTITY PUMPED: /DD GALLONS
�U,•yI� c/ans,d�
CESSPOOL-: N0 El YES G- : NO 0 YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: V( h
DATE. q. , „, `... .
INSPECTORt /3ir
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System'Owner= 9+N there and ready System Location
Kirkpatrick Pater Primary Home
409 Lafayette St 409 Lafayette St
Salam, MA, 0: 970 Salem, MA, 01970
(9781 -741-2407 x {978)-741-2407 x
Klrknat;r.ick Peter
Type: Emergen Routine
Cesspool: No / Yes Septic Tank: No Yes
Date of Pumping: `J Quantity Pumped: [ g 0() Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: t/L
Date: Pumper Signature:
Condition of System/Other Comments
(RECEIVE®
lim - 5 2007
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Form-12/07/95
- Form 4 -- System Pumping Record
Comnwnereakh of Mossachuzetss
Massachusetts
System Pumoine Record
System Owmer System Location
R :r n rr r r cret r.r Pr.;al,xy llomr,
•;. li .,.. . lr>«tor of 46v S�2ayirc l„�� St.
14k '. 'h07 n
Type: EnmW=y Routine
Cesspool: 140 ✓ Yes Septic tank: hb OYes
Date of Pumping: Q — ('—() Quon” Pumped: 1 n,nl Gallons
System Pumped By: Wind Rwr Enwra wwal,, LLC Permit#: —�l
Contents transferred to:
Contents Disposed at:
.SUP
Date: - Pamper Signature:
Condition of System/Other Comments
0
Jug 112 2004
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Form - 12/07/95