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2 Wyman Street system pumping record (1 Commonwealth of Massachusetts F RA-RECEIVED,,r� City/Town of Salem System Pumping Record MAY 17 2021 Form 4 DEP has provided this form for use by local Boards of Health.Other forms may be used,but the inforgTroYi I[st$ALEM substantially the same as that provided here.Before using this form,check with your local Board oRQARQQ1erH&WIlArm 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: 2 Wyman Street Address Salem MA 01970 City/Town State _Z_i_Code 2. System Owner: Susan Lowell Name 2 Wyman Street Address(if different from location) Salem MA 01970 City/Town State Zip Code 9784309750 Telephone Number B. Pumping Record 1. Date of Pumping 04/12/2021 2. Quantity Pumped: 1500.0000 Date Gallons 3. Component: ❑ Cesspool(s) © Septic Tank ❑Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? Yes ❑X No If yes, was it cleaned? ❑Yes 0 No 5. Observed condition of component pumped: designed to be used with a filter. Cover(s) secured. Recom B additive,CCLS additive. 6. System Pumped By: Michael Graham Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA 04/12/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1