1 Peter Road system pumping record 11-25-20 Commonwealth of Massachusetts RECEIVE®
� rn City/Town of Salem DEC 15 2020
m System Pumping Record CITY OF SALEM
Form 4 BOARD OF 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:
1 Peter Road _
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Pamela O'Donnell
Name
1 Peter Road
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
6178776125 xCell _
Telephone Number
B. Pumping Record
1. Date of Pumping 11/25/2020 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑Tight Tank ❑Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? X Yes No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System operating Eine Normal water lavel 140clerate top sol:ids Moderate bottom
_ bafflets are _ . ! _.
c eta as needed. Cover(s) secured. Pumped 15 Cgallons. 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:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
11/25/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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