4 LILY STREET SYSTEM PUMPING RECORD 11-18-21 RECE1
Commonwealth of Massachusetts MAR 14 2022
G City/Town of Salem CITY OF SALEMM'
I system Pumping Record BOARD OF HEALTH
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 Healtn or other approving autnority wrtnin 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
4 Lily Street
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Coastline Marine Service LLC
Name
4 Lily Street
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9788105448
Telephone Number
B. Pumping Record
1. Date of Pumping 11/18/2021 _ 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 r)-Cl No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
hint Applicahle water level Qj'n IDQttom sludge e W n topsol ids main litre Not
Applicabte . No fitter ts present on Lhtt Laak, uuLLent Lank is not designed to be
used with a filter. Cover(s) secured. No 3rd party paperwork i e . Removed all
gallons from totes.
6. System Pumped By:
Robert Herrick
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
11/18/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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