System pumping record 7-2-20 �,L\ Commonwealth of Massachusetts
q � City/Town of Salem
System Pumping Record
Form 4
i� DEP has provided this form for use by local Boards of Health.Other fors tl e in lion must be
substantially the same as that provided here.Before using this for,checic i o I o rd o th t determine the for
they use.The System Pumping Record must be submitted to the local So s I h r he ap i g atith
only within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
334 Highland Avenue
Address
Salem K 0 1970
cityfrown St a Code
2. System Owner:
Richard Lacha elle
Name
334 Highland Avenue
Address(if different from location)
Salem MA1, 1 1 0 70
Cityfrown Stes
Zlplr.d.e97119 h m
Tel p.oh
B. Pumping Record
1. Date of Pumping p,e 02/2020 2 Qu Go o0s 0000
3. Component: Cesspool(s) Septic Tan t a Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes No If i a ad as
No
5. Observed condition of component pumped:
m sludge
tan 15. not eslgne to a use w1t a 1 to ) e u 3Z. a Nn
Recommendatio,
6. System Pumped By:
Robert Herrick
Name V c i N b r
Wind River Environmental LLC, 577 Main-3 1 Hu son, MA 01749
Company
7. Location where contents were disposed:
HaverHill Disposal Site: 40 a Porter St, Aq r , 5
0 7 1 2I
Signature of Hauler D
Signature of Receiving Facility(or attach facility recelpt) D
t5for4.doc•11112 S to I.
pir g Record-Page 1 oft
Commonwealth of Massachusetts
q City/Town of salem
System Pumping Record
Form 4
DEP has provided this farm for use by local Boards of Health.Other form e ,I It t is i '!or must be
substantially the same as that provided here.Before using this form,chec r I rdcIHB th determine the form
they use.The System Pumping Record must be submitted to the local B F r th r ap r g a thodty within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
11 Traders Wa
Address
Salem OID70
Cltyrrown -Zr;
2. System Owner:
Shaw's Corporate Maintenance
Name
523 Spring Street
FITIFIFE-
Address(if different from location)
East Bridgewater M f�3 CiNfrown St
5) 9 D n
Tip n
B. Pumping Record
1. Dale of Pumping 07/22/2020 2 Qu 1 0.0000
Date Ga ons
3. Component: Cesspool(s) Septic Tar i t a Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑X No If 0i ared 'I es ❑ No
5. Observed condition of component pumped:
No, :1
e use wit a i tex. Covers secure um o s.
6. System Pumped By:
Marcus Lark
Name V G ' b r
Wind River Environmental, LLC, 577 Main 11 iudson, MA 01749
Company
F!
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
0
Signature of Hauler p
Signature of Receiving Facility(or attach facility receipt) D
t5form4docc 11/12 stlaii
pin Record•Page 1 of 1