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90 ORNE ST � a��'e sr Cy'�`� RECEIVED 06/16/2017 04:59PM 9787450343 Salem Health Dept 06/16/2017 16:52 9782814869 WINDRIVER PAGE 03/05 Commonwealth of Massachusetts City/Town of (/V"-_ s 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. Sy S tion: on the com r, use only the tab r _�'J,!�-'F`J�"}7 III key to move your Add cursoo use ret not MA — /"" Q/ use the return cltyrrown state Zip Code/ key. 2. System Ow r. r� i Nam raven Address(if different from location) - Cityrrown StateZip s Tom ' 5 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: uenS 3. Component: ❑ Cesspool(s) dl�lseptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observe ontlition omponent pumped: 6. System u ped B Name Vehicle License Manse Number Wind River Environmen al ver EnvIrOAffie° l Company Wind� AvG 163 Ve�T° 930 7. Location where contents were disposed: mAo] At Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.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 01/06 42070 7 7.602 71;30T10tl3 Commonwealth of Massachusetts Form 4•-System Pumping Record 8234'% Massachusetts system Pumping Record System Owner System Location Bennett Ed Primary Bome 90 Orne Street 90 Oend street Salem, TMA, O1970 Salem., mm,, 01970 ;508}•.84?-5180 x (500)-843-5780 x Sennett Ed Type: EmergenRoutine Cesspool: No yes Septic7ank: NOyes Date of Pumping: r �— Quantity Pumped: � Gallons System Pumped 8y: Wind River EnviroameNal,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments 440 .�d Dep Approved Form-12/07/95 Commonwealth of Massachusetts Salem, Massachusetts System Pumping Record Svstem Owner& Address: Robert& Rachel Lutts 92 Orne Street �� Salem, MA 01970 Location of system: Rear yard 9Rp oFs 1,� Date of Pumping: July 19, 2013 Ocyg<F Type of system: Septic Tank Gallons Pumped: 1500 gallons System pumped bv: Service Pumping& Drain Co., Inc. 5 Hallberg Park North Reading, MA 07864 License #: BHP-2012-0671,0670 License#: BHP-2013-0673,0672 Contents transferred to: South Essex Sewerage District =Date: July 19=2013_ =V , Pumping Technician JN This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes Commonwealth of Massachusetts Form 4--System Pumping Record 10% Massachusetts System Pumping Record S stem Owner•°°' y `�„ '"' - System Location Bennett Ed Primary Home 90 erne Street 90 Orne Street Salem, MA, 01970 Salem, MA, 01970 (781)-953-4979 x (508)-843-5780 x Bennett Ed Type: Emergenc Routine Cesspool: No Yes Septic Tank: No Yes Date of Pumping: 5--//— Quantity Pumped: Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature:(/'/) �� V Condition of System/Other Comments r RECEIVED JUN 0,3 2011 ® Nn,e mo ycledpa�r Dep Approved Form-12/07/95 'J Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record SystertiIbwner't'• yro-'y°'oyu; x�i> ce System Location Bennett Ed Primary Home 90 Orne Street 90 Orne Street Salem, MA, U19'lU Salem, MA, 019"/0 (781)-953-4979 x (5U8)-843-578U x Ronnot Y F.ri Type: Emergent Routine C/ Cesspool: No Yes Septic Tank: No Y41 Date of Pumping: Lam--/q - IC Quantity Pumped: /DOG Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Px Date: Pumper Signature: Condition of System/Other Comments 5ex) i ® Pnmraon.cyclwpper Dep Approved Form- 12/07/95 0222026685 IWA2003 Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record System Owner System Location Bennett Ed Primary Home 90 Orne Street 90 Orne Street Salem, MA, 01970 Salem, MA, 01970 (781)-953-4979 x (508)--843-5760 x. Bennett Ed Type: Emergent Routine Cesspool: No Yes Septic Tank: No Yes Date of Pumping: +J"' - I'�,- Quant ty Pumped: .10n n Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments tSr `LA Dep Approved Form-12/07/95 Commonwealth of Massachusetts Form a--System Pumping Record Massachusetts System Pumping RecordCj l System Owner System Location Bennett Ed Primary Home 90 Orne Street 90 Orne Street Save>m, MA, 01970 Salem, MA, 01970 (7811-953-4979 x (508) -893-5780 x Bennett Ed Type: Emergency Routine Cesspool: No I a Yes Septic Tank: No = Yes Date of Pumping: Q Quantity Pumped: oto Gallons 'L System Pumped By: Wind River Environmental,LLC Permit#: IIContents Transferred to: li Ipswich Water Contents Disposed at: Treatment Plant —+ Ipswich, MA 01938 Date: J o D Pumper Signature: 14# LU Condition of System/Other Comments ® r rVED- [JUN 6 2tl0� r OITY OF SALEM BOARD OF HEALTH L——----------- ---- -- --------- ---- -- Dep Approved Form- 12/07/95 nnnn/�{qq,�g ��nmromn Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record Sysfem'Owner System Location Bennett Ed Primary Home 90 Orne Street 90 Orne Street Salem, MA, 01970 Salem, MA, 01910 (781)-953-4979 x (508)-843-5780 x Bennett Ed Type: Emergent Routine Cesspool: No Yes Septic Tank: No Yes Date of Pumping: Q Quantity Pumped: /0790 Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments RECEIVED (JUN - 5 2001 CITY OF SALEM BOARD OF KFALTH Dep Approved Form-12/07/95 r1s11,)7 11/30003 Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record �C S J System Owner System Location Bennett Ed -i? l ify-Frdme 90 erne Street 90 erne Street Salem, PIA, 01970 5al*)M, N1A, 019"10 17811-953-497M x X508)-843-5"180 x Bennett Ed Type: Emergency Routine Cesspool: No Yes Septic Tank: No YesE � Date of Pumping Quantity Pumped: Gallons i System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments O ,e Ut 6 MAY 1 a 2006 CITY OF SAL4t,1 BOARD OF HEALi'H Dep Approved Form-12/07/95 Vf { 577 Main Street.Suite 110, Hudson. Massachusetts 01749 E-Mail: ~� hone 978.562.4500 Facsimile 978.562.7255 ENVIRONMENTAL Telephone I wrenvlron menta .Com i i May 9, 2006 Wind River Environmental 163 Western Ave. Gloucester, MA 01930 Board of Health Administrator, This package contains the dump slips for the Board of Health from the field office located in Gloucester, MA. This is the work we have completed. If you have any questions, please feel free to contact our Branch Manager, David Martin at 978-282-7315. Thank you, Jillian Elam :;!Yy OF SALEM BOARD OF HE>~: TH Form 4 -- System Pumping Record Commonwealth of Mossachusetss p Massachusetts System Pumoina Record 1� O DEC D -?®D3 CITY© l system owner ----'�� System L=ftn OF HEALTH n;e hd �D �y Primary Home MA ol,470 X51 41 9 x (?811 953-4979 x BHnnett Type: Emergency Routine Cesspool: No Yes Septic tank: w Yes I Date of Pumping: ( �-7 Quantity Pumped: /61TO r.110" System Pumped By: Wed Aker EnwanssenM/, UC Permit#: Contents trensferred to: Contents Disposed at: S S� Date: 3 pumper signature: Condition of System/Other Comments Oep Approved Form - 12/07/95 Form 4 -- System Pumping Record Commamwealth of Massachusetss Massachusetts System Pumoina Record System Owner System Location Pr unary E{..,+. go U - 'dR.r !1i1r � : .•�^ S,-:Iomf MA, 01, 87" F,pTI x. . �. Type: Emergency Routine Cesspool: w des Septic tank: hlo Elyes IZI Date of Pumping: l#la L, Quantity Pumped: J aallons System Pumped By: Wind Nver Environmental, LLC Permit M Contents transferred to: Contents Disposed at: Date: Pumper Signature: )� ' Condition of Systean/Other Comments Dep Approved Form - 12/07/95 i 07/03/2012 15:05 9782814869 WINDRIVER PAGE 03/04 Commonwealth of Massachusetts Form 4--System Pumping Record L25g% Massachusetts ] ns-: System Pumping Record System wnar' "' " �V` System Location Bennett Ed. Primary Home 90 Orne Street 30 Orne Street Salem, 1A, 01970 Salem, 14A, 01970 (781)-953-4919 x {508}-043-5780 x Bennett Ed TYPV Emergen Routine Cesspool: No . Yes Septic Tank: No O Yeg� ""'� Date of Pumping: S`,-'�(,- 12' Quantity Pumped/n-4� ; Gallons System Pumped By Wind River Environmental,LLC Permit#: Contents Transferred to: i Contents Disposed at: Salem. MA. N. ~yl )ate: Pumper Signature: Andition of System/Other Comments / P n Aon enwcupap r Dep Approved Form-12/07/95 06/22/2015 23:52 9752814865 WINBRIVER PAGE 08,109 02070f306roo 11E3t7t3QiJ3�` .``J - '- Commonwealth of Massachusetts Farm 4-System Pumping Record' Massachusetts System Pumping Record r System Owner System Location Bennett Ed Primary Home 90 Grne Street 90 Orne Street Salem, 14A, 01970 I Salem, MA, 01770 (508)—E43--5780 x (508)-893-5760 x Bennett Ed Type: Emergen Routine Cesspool: No .-r Yes Septic Tank: N Yes Date of Pumping: �L .! �' (.KJ Quantity Pumped: t+ Gallons i System Pumped By: Wind River Environmental,LLC - Permit# Contents Transferred to: '.. Contents Disposed at: Salem a� A )ate: j t Pumper Signature: 1' :ondition of System/Other Comments I' Dep Approved Perm-12/07/95 06/12/2013 13:31 9782814869 WINDRIVER PAGE 02/02 :a ;. dlt:i4le,d9 1?/3G{2003 Commonwealth of Massachusetts Form 4--System Pumping Recor Massachusetts System Pumping Record System Owner System Location Bennett Ed Primary Home 90 Orme street 90 Orne Street Salem, Mo,, 01970 Salem, MA, 01970 (78.1)-953-4979 x (508)-895-5780 x Bennett Ed Type: Emergent Routine Cesspool: No Yes Septic Tank: No Yes�r Date of Pumping: 13 Quantity Pumped: d 60 Gallons System Pumped 8y: Wind River Environmental,Us Permit#: Contents Transferred to: Contents Disposed at: �+ c Salem, MA. Date: Pumper Signature: Condition of System/Other Comments ® Prinreaonrc0•�Wpap¢r Dep Approved Form-12/07/95