Loading...
System pumping record 9-14-20 SZ�, Commonwealth of Massachusetts as City/Town of Salem Vo; System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health.Other form t t oa ir x v itiormust be substantially the same as that provided here.Before using this form,the 1 o rtl Ith determine the form the use.The System Pumping Record must be submitted to e local B tl h r N r a g a thodty within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 3 Mckinley Road Address Salem 01 970 City/Town S� a ode 2. System Owner: Carmen Labreccrue Name 3 Mckinley Road Address(if different from location) Salem 011 70 City?own SigZi ode 9 7 TIp B. Pumping Record 1. Dale of Pumping 09/14/2020 2 Qu 1 0.0000 Date G ons 3. Component: Cesspool(s) Septic Tat I i t ral Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑Yes ❑X No If v 3; i ol ar ad as ❑ No 5. Observed condition of component pumped: cuczent tan rs noh esigne to a use wat v Recommended Boost additive,CCLS additive. 6. System Pumped By: Michael Graham Name Vf t cl 1 Wind River Environmental LLC, 577 Main 36 . t 1 Hu. son, MA 01749 Company 7. Location where contents were disposed: HaverHill Disposal Site: 40 s Porter St, m j K. 0 0 Signature of Hauler D t Signature of Receiving Fadlity(or attach facility receipt) D t5form4.tloc•11112 S ste Ili in' Record i p d Page 1 of 1 -\ Commonwealth of Massachusetts City/Town of Salem S Systemm Pumping Record � Form 4 DEP has provided this form for use by local Boards of Health Other form t t e i tior must be substantially Me same as that provided here.Before using Nis form,the I o of Ith I determine the form they use.The System Pumping Record must be submitted to the local Sctl F ifth r th rap g a thority,within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 12 Haves Road Address Salem 01 970 City/Town ode 2. System Owner: Carmen Labrec ue Name 12 Hayes Road Address(If different from location) Salem MA 03 D70 Cityfrown S 5 ZI ode 9 3 3 Tip ' B. Pumping Record 1. Date of Pumping 09/14/2020 2 Qu 1 O.000 Date Ge ons 3. Component: Cesspool(s) Septic Tar hilt a GreasI Trap Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If i a ad es ❑ i o 5. Observed condition of component pumped: Ld current tan rs not esrgne to a use wat v r I ec re a. Recommended Boost additive,CCLS additive. B. System Pumped By: Michael Graham Name vet I Ii b r Wind River Environmental, LLC, 577 Main 'el 11 u son, b1A 01799 Company 7. Location where contents were disposed: HaverHill Disposal Site: 90 s Porter St, 4&14C W 0 S Signature of Hauler Dab Signature of Receiving Facility(or attach facility receipt) D t5form4.dov 11/12 S to P pin Record•Page i of 1 ,a Commonwealth of Massachusetts City/Town of Salem System Pumping Record Form 4 _ DEP has provided this form for use by local Boards of Health.Other forrrm�s ul a llo must be substantially the same as that provided here.Before using this form,ched v Be Ird t lith o determine the form they use.The System Pumping Record must be submitted to the local Bo ti, Ith r at n ig thority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 409 Lafayette Street Address Salem M 0 .970 City/Town St Zi Qgde 2. System Owner: Peter Kirkpatrick Name 409 Lafa ette Street Address(d different from location) Salem Ma 0 970 Cityfrown -911e Zi Code 9 b s Tel p ' n B. Pumping Record 1. Date of Pumping 09/02/2020Date 2. Ou pE I 1 00.0000 G ons 3. Component: ❑Cesspool(s) Septic Ta 1 i t rar IGrease Trap Other(describe): 4. Effluent Tee Filter present? ❑Yes ❑X No If i cll Bled ' es No 5. Observed condition of component pumped: t95F is not esigne to a use wit a i tex. F e u Pu pe 1500gallons. Recommended No Recommendation. 6. System Pumped By: Marcus Lark Name VelIh -1 lie b r Wind River Environmental, LLC, 577 Main 3ja, � 11 u son MA 01749 Company 7. Location where contents were disposed: 163 Western Ave, Gloucester, MA 01930 09 0 �ignatumof Hauler Dolt Signature of Receiving Facility(or attach facility receipt) Dat I t5fomn4.doc•11112 S le P pin Record•Page 1 of 1