8 CEDARCREST ROAD SYSTEM PUMPING RECORD 12-14-21 Commonwealth of Massachusetts
,i 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:
8 Cedarcrost Road,
Address
Salem MA 01970
City/Town State _ Zip Code
2. System Owner:
Nadir B_endienni
Name
8 Cedarcrost Road,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
6179438716 x
Telephone Number
B. Pumping Record
1. Date of Pumping Date 12/14/2021 2. Quantity Pumped. Gaallonsllons 000
3. Component: ❑ Cesspool(s) Septic Tank ❑Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑] Yes No If yes, was it cleaned? X❑Yes ❑ No
5. Observed condition of component pumped:
sludye. Buth baffles are intaut. Main line CleaL. ftlteL ts present cuid has been
c-Ieaneff as needed. Cover(s) secured. Recommen e Boost ad itive,CCL-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:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
_ 12/14/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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