3A Winter Island Road system pumping record 12-8-20 RECEIVE®
i Commonwealth of Massachusetts
JAN 0 7 2021
N City/Town Of Salem
System Pumping Record CITY OF SALEM
Y P BOARD OF HEALTH
z Form 4
Is e 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:
3A Winter Island Rd
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Winter Island Park
Name
3A Winter Island Road
Address(if different from location)
Salem MA 01970
CitylTown State Zip Code
9787453797
Telephone Number
B. Pumping Record
12/08/2020 1000.0000
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
3. Component: ❑Cesspool(s) Septic Tank ❑Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes M No if yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
N- armal wati;�r le-el 34n bottom sludge ] in top solids Main 1�ne Not Appl :icable
Lhe ranki
cu:i.Lkamt: ',dift is nut designed tu be used with a
filter. Cover(s) secured.
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
12/08/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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