3 CEDAR HILL ROAD SYSTEM PUMPING RECORD 12-6-21 Commonwealth of Massachusetts
ra City/Town of Salem
System Pumping Record
` Form 4
' .y 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:
3 Cedarhill Road,
Address
Salem MA 01970
City/Town State Zip,Code
2. System Owner:
Paul Crowell
Name
3 Cedarhill Road,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787453116 x
Telephone Number
B. Pumping Record
1. Date of Pumping 12/06/2021 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 ❑X No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
System Operating Fine Normal water lavtAl Moderate top Rolidg- Mnderatg batt=
studge. Buth baffles are ±ntact:. Main line CteaL. No fill-I present on tile tdn-k—,
current tank is not designed to be used wit.. a filter. Cover(s) secure .
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:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
12/06/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1