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1 DIPIETRO AVENUE SYSTEM PUMPING RECORD 2-21-22 Commonwealth of Massachusetts City/Town of salem System Pumping Record 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: 1 Dipietro Avenue, Address Salem MA 01970 City/Town State Zip Code. 2. System Owner: Susan Spinale _ Name 1 Dipietro Avenue, Address(if different from location) Salem MA 01970 City/Town State Zip Code 6177210395 x Telephone Number B. Pumping Record 1. Date of Pumping 02/21/2022 2. Quantity Pumped: 1000.. o000 Date Gallons 3. Component: ❑ Cesspool(s) © Septic Tank ❑Tight Tank Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑Yes ❑X No If yes,was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: illtdUt. Mdill line CledL. No fitter is present oil the tdnk; current t�ililc ts not: designed to be used with a filter. over(s) secured. Recommended Boost additive,CCLS additive. 6. System Pumped By: Michael Graham _ 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 02/21/2022 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1