SYSTEM PUMPING RECORD 8-26-20 L\ Commonwealth of Massachusetts
City/Town of sales
System Pumping Record
be
substantially the same as that provitled here.Before using this form,the e l t e in tion mustrm
Form 4
DEP has provitled this form for use by local Boards of Health.Other forms
y .1 o rd th t determine the form
they from The System Pumping Record must be 10CMR to the local B it a 11 p o I' g a hodty within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
3 Cedarhill Road
Address
Salem 0 970
City/Town ode
2. System Owner:
Paul Crowell
Name
3 Cedarhill Road
Address(if different from locefion)
Salem MA 0 70
City?own Sir Zip Cotle
97 V 1
Tel p
B. Pumping Record
1. Date of Pumping 08/26/2020
Date 2. Qua 1 0.0000
Ga Ions
3. Component: Cesspool(s) Septic Tari t a Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑X No If,V as ONO
5. Observed condition of component pumped:
a bottom
current tank is not des—ig—n—ecT to be used wit iltilv r ec ire . Pumpe
1500gallons. Recommended Boost additive,CCLS t
6. System Pumped By:
Marcus Lark
Name W d Li r
Wind River Environmental LLC, 577 Main S ll 1, u son, MA 01749
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
08
Signature of Hauler Dat
Signature of ReceNing Facility(or adach fadlity receipt) O
t5form4.doc•11/12 S to pin Record•Page 1 of 1
�L\ Commonwealth of Massachusetts
yst of Salem
S
Systemm Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other fors 1 10 bn L M t I t e in too must be
substantially the same as that provitletl here.Before using this form,check o i oa IJ o t determine the form
they use.The System Pumping Record must be submitted to the local Boa I he ap a hmity within 14
days from the pumping date In accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
1 Di ietro Avenue
Address
Salem 01970
Citylrown Zi
2. System Owner:
Susan S inale
Name
1 Di ietro Avenue
Address(If different from location)
Salem MA 01970
City/rown Ste Zip code
61 I I c 11
Tel n
B. Pumping Record
1. Date of Pumping 08/03/2020 2. Qui t e 10I0.0000
Date Ga 'ons
3. Component: Cesspool(s) ❑Septic Tad i t an Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes ❑R No If y !I A a ed as No
5. Observed condition of component pumped:
tank; current tank is not designed to be use i e to r secure .
Pumped 1000 gallons. Recommended No Recommentl
6. System Pumped By:
Marcus Lark
Name Veh 1 4i N b r
Wind River Environmental, LLC 577 Main S I 11 u son MA 01749
Company
7. Location where contents were disposed:
08 /
Signature of Hauler Dot
Signature of Receiving Facility(or attach fadlity receipt) D
t5form4.doo 11112 S e P pin Regard•Page 1 of i
Commonwealth of Massachusetts
CitylTown of Salem
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other tons k t if e inthin,must be
substantially the same as that provided here.Before using this form,cheer vi V o sl oe r o th t !determine the form
they use.The System Pumping Record must be submitted to the local Bomill I 1r he apiI,110i g a thistly within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
23 Cedarcrest Avenue
Address
Salem MA 01970
Cityfrown St Zi c ads
2. System Owner:
Peter Maitland
Name
23 Cedarcrest Avenue
Address(it different from location)
SalemMA 01970
Cityrrown Sla Zip Code
97 H an
Te A 40440ni
B. Pumping Record
1. Date of Pumping 08Dat 14/2020 2 Qua t 1105 0000
3. Component: Cesspool(s) Septic Tan l i t an Grease Trap
Other(describe):
I
4. Effluent Tee Filter present? ❑X Yes ❑No If y ii A I it cl a ad' es ❑ No
5. Observed condition of component pumped:
nee a over s secure Reparrs needed: Cost q of o ouse to
city sewer. Recommended No Recommendation.
6. System Pumped By:
Robert Herrick
Name Ve b r
Wind River Environmental, LLC, 577 Main S 11 1, u son MA 01749
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
08
Signature of Hauler Dat
Signature of Receiving Facility(or attach facility receipt) Dat
t5fomM.doc•11/12 Syste1pin Record•Page 1 of 1
�L\ Commonwealth of Massachusetts
OCity/Town of Sa1erB
System Pumping Record
w Form 4
DEP has provided this form for use by Intel Boards of Health.Other forms) t e in ion must be
substantially the same as that provided here.Before using this forth,check i I u o 1 o d o h determine the form
they use.The System Pumping Record!must be submitted to the local Boa �r a ap b ,,a, odty within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
17 Crowdis Street
Address
Salem MA 01970
City ra m so Zia ode
2. System Owner:
Ninh Nguyen
Name
17 Crowdis Street
Address(ff different from location)
Salem MA 0 970
City/rown Sta Zip Code
78
Tel p
B. Pumping Record
1. Date of Pumping Date 26/2020 2. Qu I OO$0000
3. Component: ❑ Cesspool(s) Septic Targi i t a Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes No Ifll �c a ed es No
5. Observed condition of component-sya
tan ; current tan 1s not designedto a usel 1 e III r secure is
is a e enviro pump chamber u have to remove SE p m ur custumer is
home hall helpu. Recommended CCLS additive.
6. System Pumped By:
Marcus Lark
Name Volmfj� N r
Wind River Environmental, LLC, 577 Main S 1 Hu son, NA 01799
Company
7. Location where contents were disposed:
NEMO Yard: 59 Knox Trail, Acton, MA 01720
08 2 ,
Signature of Hauler Da
Signature of Receiving Facility(or atlachh facility receipt) Oa 'i
t5forrM.tloc•11112 S to pi g Record-Page 1 of 1