SYSTEM PUMPING RECORDS 2001-2016 RECEIVED 01/27/2017 03:50PM 9787450343 Salem Health Dept
01/27/2017 15:43 9782814869 WINDRIVER PAGE 04/07
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Commonwealth of Massachusetts Form 4--System Pumping Record O7*
Massachusetts
System Pumping Record
System Owner System Location
Ct'�kY-=1-i P.aL'1 Pi:]at3['a ,Tirame
C'e[iat Flill Rpsd 3 Cedar Rill RGAd
2a5em, Kia, 01970 Salem, MA; 01970
;a 76,-745- 315 (978)-745-3116
Crowell
Type: Emerges Routine
Cesspool: No Yes Septic Tank: Ne Yes®/
Date of Pumping: .v. Quantity Pumped: O'D Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature;
Condition of System/Other Comments
® Pnmroow �imc � Dep Approved Form-12/07/95
\ Commonwealth of Massachusetts
City/Town of Salem
System Pumping Record
,p 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 ca Boar f
Board o 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 1. System Location:
forms on the
computer,use 3 Cedarhill Road
only the tab key Address
to move your Salem MA 01970
cursor-do not City/Town use the return b State Zip Code
key.
2. System Owner:
Paul & Rebecca Crowell
Name
Address(if different from location)
City/Town State Zip Code
978-745-3116
Telephone Number
B. Pumping Record
1. Date of Pumping 6/9/11 750
p 9 Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ 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. Condition of System:
Good Condition.
6. System Pumped By:
Dustin Prieur K84568
Name Vehicle License Number
PSAD LLC
Company
7. Location where contents were disposed:
Ipswich waste water treatment plant
-F i�/1ce dam_ 6/10/11
ign
P ature of Ha I Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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Please call with questions/concerns
We appreciate your business
Septic System Function�rCheckand Pumping Deport
Property Owner's Name: M d Well
Property Address:
Date of Pump/Function C eck: J
Routine: N' Emergency: ❑ Technician
SEPTIC TANK SYSTEMSingle Compartment" El DoubleCompartment
*YES indicates there is a robl m, NO indicates there is noproblem
YES NO
Tank structure
Breakout or ponding
Liquid level above inlet invert
Liquid level above outlet invert
Tee or Baffles missing or broken inlet
Tee or Baffles missing or broken outlet
FILTER PRESENT ❑ Yes A No TYPE:
Condition:
❑Cleaned ❑Replaced ❑Installed IB�16
TANK LEVELS AND MEASUREMENTS
AUG 14 2006
Size of tankCITY OF SALEM
Actual amount pumped 5Q BOARD OF HEALTH
Scum layer (acceptable range 1-2") Jti
Sludge depth (acceptable range 5-10)
Liquid level d
OVERFLOW TANK PRESENT ElYd/1KNo
Size of tank
Actual amount pumped
Liquid level
Condition
COMMENTS: Cd A/ M
Form 4 -- System Pumping Record
Commonwealth of Massachusetss
: Massachusetts
System Pumnino Reurd
System Owner System location
Paul Crowoll Paul
3 cedar hill rd 3 cedar hill rd
Salon. MA 01970 Salem, HA 01970
(976) 745-3116 (970) 745-3116
Type: Emergency Routine
Cesspool: Mo Yes Septic tank: t4- =Yes E
Date of Pumping: Quantity Pumped: Soo Gallons
System Pumped By: Wind Riney&Wronmenta/, LLC Permit#:
Contents transferred to:
i
Contents Disposed at: ` �5
Date: a !/6 Pamper Signature:
Condition of System/Other Comments
r 1 7 NO
�u
CITY OF SALEM
HEALTH DEPT.
Dep Approved From - 12/07/95
08/06/2014 14:35 9782814869 WINDRIVER PAGE 01/,14
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Commonwealth of Massachusetts Form 4—System Pumping Record a_gq%
Massachusetts
System Pumping Record
System Owner System Location
Crowell Paul Prinary Home
3 Cedar Hill Road 3 Cedar Hili Road
Salem, KA, 01970 Salem, Kk, 01970
(978)-795-3116 x (978)-745-313.6 x
Crowell
Type. Emergen Routine
=esspool: No /! Yes Septic:Tank: No .yes�'
)ate of Pumping: y n_�C� Quantity Pumped: I LbCJ Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
:ontents Transferred to: ..
:ontents Disposed oti
M MA.
)ute: Pumper Signature-
:ondition of System/Other Comments -17
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1-666.666.6214
ns�«nmrc�y�t�av^ar Dep Approved Form-12/07/95 N