10 BARNES AVENUE - SYSTEM PUMPING RECORD 10-27-21 RECEIVED
Commonwealth of Massachusetts
-- DEC 0 9 2021
City/Town of Salem
'ol System Pumping Record BOCITY OF AR OF HEALTH
Form 4 H
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:
10 Barnes Avenue
Address
Salem _ MA 01970
City/Town State Zip Code
2. System Owner:
Carolyn Tori ian _
Name
10 Barnes Avenue
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9785875577
Telephone Number
B. Pumping Record
1. Date of Pumping 10/27/2021 2. Quantity Pumped. 1000.0000
Date Gallons
3. Component: Cesspool(s) u Septic Tank ❑Tight Tank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? [x:] Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine High water lavel MndQrate top solids Modarate hottoo
cleaned been-
cleaned as needed. over(s) secured. Pumped gailons. Recommended Boost
additive,CCLS 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:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
10/27/2021
ignature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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