Loading...
1 DIPIETRO AVENUE SYSTEM PUMPING RECORD 11-1-21 RECEIVED Commonwealth of Massachusetts MAR 14 2022 lea City/Town of Salem CITY OF SALEM '., r System Pumping Record BOARD OF HEALTH _� Form ^=-rti= 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: 1 Di ietro Avenue Address Salem MA 01970 City/Town State Zp Code 2. System Owner: Susan Spinale Name 1 Di ietro Avenue, Address(if different from location) Salem MA 01970 City/Town State Zip Code 6177210395 x Telephone Number B. Pumping Record 1. Date of Pumping 11/01/2021 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 © No If yes, was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: System operating Rine Normal water I ave, Moderate top solids Moderate hotto= current tank is not designed to be used with a filter. Cover(s) 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: Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA n 11/01/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1