4 Eleanor Road system pumping record RECEIVED
Commonwealth of Massachusetts MAY 17 2021
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CITY OF SALEM
System Pumping Record BOARD OF HEALTH
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
1. System Location:
4 Eleanor Road
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Kathleen And Eric Thomas and Martin
Name
4 Eleanor Road _
Address(if different from location)
Salem MA _01970
City/Town State Zip Code
9787445343
Telephone Number
B. Pumping Record
1. Date of Pumping 04/12/2021 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank ❑Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
Sy2tem OpQrating Fine Normal water level UlGdgrate top R01jd2 Moderate bottc=
current tank is not esigned to be used with a filter. Cover s secured.
Recommended Boost 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
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