System pumping record 1-18-21 Commonwealth of Massachusetts
u City/Town Of Salem
System Pumping Record
Form 4
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
I. System Location:
1 Dipietro Avenue
Adaresa — _
Salem MA 01970
Cgy/rown Mate Zip Code
2. System Owner:
Susan S inale
Name
1 Di ietro Avenue
Address ddffaremhom.cation)
Salem
Cdyrr— State 01970
ZiP Code
6177210395 xcell
Telephone Number
B. Pumping Record
1. Date of Pumping pie 18/2021 2, quantity Pumped: 1000.0000
Gallon
3. Component: ❑Cesspool(s) Septic Tank Tight Tank Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? ❑Yes®No If yes, was it cleaned? ❑Yes ❑No
5. Observed condition of component pumped:
' �trYta —F t tit a--Ca,nr;
current not ergne to a use w a i er, over a secure . umpe
1000 9a11ona.1Reconmended 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
O"18/2021
Signature of Hauler Data
Signature of ReceNing Pacillty(a attach facility receipt) Date
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