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15 BRIDGE STREET SYSTEM PUMPING RECORD 9-11-21 RECEIVE® Commonwealth of Massachusetts OCT 2 7 2021 Z? City/Town of Salem CITY OF SALEM �a System Pumping Record BOARD OF HEALTH _c 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: 15 Brid_;e Street Address r Salem MA 01970 City/Town State Zip Code 2. System Owner: Restaurant NinetV, Nine Name 14A Gill Street, Address(if different from location) Woburn MA 01801 Cityfrown State Zip Code 8664618372 x4 Telephone Number B. Pumping Record 1. Date of Pumping 09/11/2021 2. Quantity Pumped: 2000.0000 Date Gallons 3. Component: Cesspool(s) © Septic Tank ❑Tight Tank Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑Yes © No If yes, was it cleaned? ❑Yes No 5. Observed condition of component pumped: Normal water to of din hottom sludge 3-n_t.op solids Both baffles ,aro Jntact Mdill lille Clt--dL. NU filtUL ±:�i PLe�elit U11 tlie tank, current tank ±s not designed Loi ❑e used with a filter. Cover s secure '-No 7ro party paperwor7i ri_ .e . Pumperj ._uo gallons of grease. 6. System Pumped By: Jason Tedesco Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste 4110, Hudson, MA 01749 Company 7. Location where contents were disposed: 163 Western Ave, Gloucester, MA 01930 09/11/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1