23 Grove St. system pumping record Salem April, 2020 Wind River Environmental
Date of Pumping Name System Location Gallons
Source a Pumped Dumped
Pumped y
4/22/2020 Kernwood Country Club 1 Kernwood Street 2500 Grease Graham South essex sewerage district
4/24/2020 McManus 23 Grove Street 1000 Septic Tank Graham Water Solutions Group
Commonwealth of Massachusetts
City/Town of SG r�
_ 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, -
use only the tab (6 Pam/'J .�
key to move your Address
cursor-do not S`'t
use the return City[Town State Zip Code
key.
2. System Owner:
_-
Name
Address(if different from location)
City[Town State q Zip Coo}de
Telephone Number
B. Pumping Record
1. [late of Pumping � Z 2. Quantity Pumped:
Date 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:
t/�Lr
6, System Pumped By:
Name Vehicle License Number
1l
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
--- —{� City/Town of
gWlSyy�
stem Pumping Record
�� Form 4
y
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 3 / ���� S�
use only the tab G lX
key to move your Address
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
r� !�Y 'Mr S
Name
Address(if different from location)
City[Town State Zip Code
� r r, Q--�—!— � C
Telephone Number
B. Pumping Record I
1. Date of Pumping D Z 2. Quantity Pumped: Gallons
3. Component: Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 4 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name Vehicle License Number
Company S.E.5.D.
7. Location where contents were disposed: , MA.
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1