6 Peter Road system pumping record 10-16-20 Commonwealth of Massachusetts R E C E I VE D
g City/Town of Salem
System Pumping Record DEC 012020
q` Form 4 CITY OF SALEM
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the informatig(MAbOF HF TH
substantially the same as that provided here.Before using this form,check with your local Board of Health to determine the r
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 CMD 1-5.351.
A. Facility Information
1. System Location:
6 Peter Road
Address
Salem _ MA 01970
Cityfrown State Zip Code
2. System Owner:
Maria Kouris,
Name
6 Peter Road _
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787446747 xHcme
Telephone Number
B. Pumping Record
1. Date of Pumping 10/16/2020 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) u Septic Tank ❑Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
System Operating Rine Normal water I Q"Q I Light top solids pdoderatQ bott=
current tank is not designed to be used w= a 1 ter. Cover(s) secured.
Recommended Boost additive,CCLS additive..
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:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
/IV— 10/16/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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