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9 CEDARCREST ROAD SYSTEM PUMPING RECORD 12-7-21 Commonwealth of Massachusetts T 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: 9 Cedar Crest Road, Address Salem MA 01970 City/Town State _ _ Zip Code 2. System Owner: Michael Patruno Name 9 Cedar Crest Road, Address(if different from location) Salem MA 01970 City/Town State Zip Code 9787451337 x Telephone Number B. Pumping Record 12/07/2021 1000.0000 1. Date of Pumping Date 2• Quantity Pumped. Gallons 3. Component: Cesspool(s) © Septic Tank F 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: systQm Upgrating Fine Normal watax: level Moderate top solid2- Moderate hQttmm 51udye. Buth baffles &.Le intdut. Main line Cleciz. No filt— IS yl"SMTL 011 tile tank—, current tankis not esigne to be used with a i ter. over s secured. Pumped 1000 gallons. Recommended Boost additive,CCLS additive. PAID BY CHECK 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: Greater Lawrence Sanitary District : 240 Charles Street North Andover, MA 12/07/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1