23 CEDARCREST AVENUE SYSTEM PUMPING RECORD 9-27-20 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 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. i ne system Pumping Record rlwsL ue submiduti iv the local Board of Hes;6,v.,uYier authority 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 f MA 01970
CitylTown State Zip Code._
2. System Owner:
Peter Maitland _
Name
23 Cedarcrest Avenue
Address(ff ddifferent from location)
Salem MA. 01970
citylTown State Zip Code
9787453913 xHOme
Telephone Number
B. Pumping Record
09/27/2020 2500.0000
1. Date of Pumping bate -~ 2. Quantity Pumped: 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? 2]Yes No
5. Observed condition of component pumped:
N al .ester level Tight 19jdc Tight ho+-+-QM Sl A e Troth baffl are j-Atant
5
secured. A people using systerul--u-TT-ed-M'0`O—ga ons. ecoinaien ie No Re-commen ad—tom
6. System Pumped By:
Justin Beaudoin
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company — _ —
7. Location where contents were disposed:
_09/27/202_0 _
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11112 System Pumping Record•Page 1 of 1