17 Crowdis Street system pumping record 9-15-21 DECEIVED
Commonwealth of Massachusetts OCT 2 7 2021
7 City/Town of Salem CITY OF SALEM
m' System Pumping Record BOARD OF HEALTH
y
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:
17 Crowdis Street,
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Nina Nquyen
Name
17 Crowdis Street, _
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
7817602615 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/15/2021 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑cesspool(s) ❑X Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes Lai If yes,was it cleaned? ❑Yes No
5. Observed condition of component pumped:
Sjz3tQM Qperat�ng Eine Normal I-Tatar IQ77R] Mnderate top solids Moderate bottom
sludge. Buth baffles are tiftact. Main ttrie Cte -L. No fttter is present on th- tank
current tank is not designed to be used with a rilter. cover is) secured. Pumped
1000 gallons. Recommended No Recommendation.
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
09/15/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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