28 CHERRY HILL AVENUE SYSTEM PUMPING RECORD 10-27-20 RECEIVED
Commonwealth of Massachusetts
Yes City/Town of Salem DEC 012020
System Pumping Record CITY OF ALEM
BOARD OF
_ + Form 4 HEALTH
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
1. System Location:
28 Cherry Hill Avenue
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Terry Avery.
Name
28 Cherry Hill Avenue
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787458208
Telephone Number
B. Pumping Record
1. Date of Pumping 10/27/2020 2 Quantity Pumped: 1000.0000
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? ❑X Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine Normal ulater 1-aval Light top SOIW2 modal2atg bottom
cleaned as needed. Cover s secured. Everything looks o no need to add anyanyirt
around cover. Recommended No Recommendation.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
10/27/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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