6 Eleanor Road system pumping record 12-1-20 �\ Commonwealth of Massachusetts R E C E V E
rn City/Town of Salem
JAN 0 7 2021
System Pumping Record
Form 4 CITY OF SALEM
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the infaMR[r OPNEALT�
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:
6 Eleanor Road
Address
Salem MA 01970
City/Town State _ Zi,.Code
2. System Owner:
Tom & Shannon Lambert.
Name
6 Eleanor Road
Address(if different from location)
Salem MA 01970
City]Town State Zip Code
9789980027 xTom
Telephone Number
B. Pumping Record
1. Date of Pumping 12/01/2020 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑Cesspool(s) FV7 Septic Tank Tight Tank R Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes FV-j No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
Moderatesystem operating Pine Normal water le!-zel top solids Moderate bottom
arre ±11tact. itfdL , tile Lantt j
current tank 15 not designeT to be used with a filter. Cover(s) secured.
Recommended Boost additive,CCLS additive.
6. System Pumped By:
Robert Herrick
Name Vehicle License Number
Wind River Environmental, LL•C, 577 Main Street, Ste #110, Hudson, MA 01749
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
12/01/2020
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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