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11 CEDARCREST ROAD SYSTEM PUMPING RECORD 11-3-21 RECEIVE Commonwealth of Massachusetts MAR 14 2022 City/Town of Salem != - System Pumping Record BOAR o HEM TH �. 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 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: 11 Cedar Crest Road Address Salem MA 01970 City/Town State Zil.Code 2. System Owner: Glen Jordan Name 11 Cedar Crest Road Address(if different from location) Salem MA 01970 City/Town State Zip Code 9783982958 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 0 No If yes, was it cleaned? ❑Yes 0 No 5. Observed condition of component pumped: System nct Operating Fine High water level Moderate top solids Moderate bottom current tank is not designed to be used with a fliter. 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: 163 Western Ave, Gloucester, MA 01930 "'v1,; 11/03/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1