28 CHERRY HILL AVENUE SYSTEM PUMPING RECORD 5-11-21 Commonwealth of Massachusetts RECEIVED
F City/Town of salem JUN Q 7 2021
- - System Pumping Record
Jf' Form 4 CITY OF SALEM
.� B0�4RD OF HF��LTH
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the in ormation mus
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 ni ithority smithin 14
days from the pumping date in accordance with 310 CMR 15.351. y
A. Facility Information
1. System Location:
28 Cherry Hill Avenue
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Terry Avery
Name
28 Cherry Hill Avenue
Address(if different from location)
Salem _ 114A 01970
City/Town State Zip Code
9787458208
Telephone Number
B. Pumping Record
1. Date of Pumping 05/11/2021 2. Quantityp Pum ed: 1000.0000
p g Date Gallons
3. Component: ❑ Cesspool(s) FV7 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? R] Yes No If yes,was it cleaned? 0 Yes No
5. Observed condition of component pumped:
System Operating 23ne No=al water le'rel -moderate top solids Moderate bottom
bafflessludge. Botli t L it�ar. Filtex -
cleaned as needed. Cover(s) securea. Pumped gallons. Recommended Boost
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
05/11/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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