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471 HIGHLAND AVENUE SYSTEM PUMPING RECORD 11-18-21 RECITED , Commonwealth of Massachusetts MAR 14 2022 I _ City/Town of Salem CITY OF SALEIM i BOARD OF HEALTH _- System Pumping Record J 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: 471 Highland Avenue Address Salem MA 01970 City/Town State Zip Code 2. System Owner: Malone Fence Name 471 Highland Avenue Address(if different from location) Salem MA 01970 City/Town State Zip Code 9782658391 Telephone Number B. Pumping Record 1. Date of Pumping 11/18/2021 2. Quantity Pumped: 1500.0000 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: Norma] water i aval 3i n bottom sludge n;n top sa.lids Roth bafflesare intact e used with a filter. Cover(s) secure . No sr�[ party paperwork i. - e . Customer has wood over cover. 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 11/18/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1