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26 Chandler Road system pumping record 10-22-20 Commonwealth of Massachusetts l' 3 City/Town Of SalemRECEIVED �4 System Pumping Record Form 4 DEC 012020 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 He l r 1 form they use.The System Pumping Record must be submitted to the local Board of Health or other appr�V i±j�f'I days from the pumping date in accordance with 310 CMR 15.361. VVVV A. Facility Information 1. System Location: 26 chandler road Address Salem MA 01970 City/Town State Zip Code 2. System Owner: David Nelson Name 26 chandler road Address(if different from location) Salem MA 01970 City/Town State Zip Code 5085588086 Telephone Number B. Pumping Record 1. Date of Pumping 10/22/2020 2. Quantity Pumped: 1500.0000 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? ❑Yes 0 No 5. Observed condition of component pumped: System Operating Fine NQi2mal wata7.c leval Moderate tQP sol-ids- mod.arate bottam- current tan . is not designe to e use wit a ilter. Cover(s) secured. Pumped 1500gallons. Recommended Boost additive,CCLS additive. 6. System Pumped By: Marcus Lark 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 A .-._ �` 10/22/2020 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1