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6 PETER ROAD SYSTEM PUMPING RECORD 11-3-21 Commonwealth of Massachusetts RECEIVED _ City/Town of saiem MAR 14 2022 System Pumping Record ci TY OF SALEM 1= Form 4 BOARD OF HEALTH =M- 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: 6 Peter Road, Address Salem MA 01970 City/Town State Zip Code 2. System Owner: Maria Kouris, Name 6 Peter Road, Address(if different from location) Salem MA 01970 City/Town State Zip Code 6178996542 x Telephone Number B. Pumping Record 1. Date of Pumping 11/03/2021 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: Sy2tew Operating R�na Normal ;,iater leval Moderate tc�p 2olids Moderate bottom — Buth bafftes are intact. Main tine Ctear. No f±t11 P.—lit U11 the Lmiki current tank is not designed to be used with a filter. Cover(s) secured. Pumped 1000 gallons. 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: 163 Western Ave, Gloucester, MA 01930 11/03/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1