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3A WINTER ISLAND ROAD SYSTEM PUMPING RECORD 11-22-21
RECEIVED Commonwealth of Massachusetts MAR 1 4 2022 r�= City/Town of Salem System Pumping Record CITY OF SALEM Form 4 BOARD OF HEALTH 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.1 ne System Pumping Recoro must be suomittea to the locai boars of Health or other approving autnonty within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 3A Winter Island Rd Address Salem MA 01970 City/Town State Zip Code 2. System Owner: Winter Island Yacht Yard Name 3A Winter Island Road Address(if different from location) Salem _ MA 01970 City/Town State Zip Code 9787453797 Telephone Number B. Pumping Record 1. Date of Pumping 11/22/2021 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: Normal water level Oin bottom sludge Oin tnp solids Ma�p line Not Appl:icable No fitter :Ls present un the tank, current tank ±s not destgned to be used with a filter. No -3rd party paperwork filied. Removed 1000 gallons wash water. 6. System Pumped By: Robert Herrick 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 _ P 11/22/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1