11 CEDARCREST ROAD SYSTEM PUMPING RECORD 1-18-22 Commonwealth of Massachusetts
City/Town of Salem
System Pumping Record
Form 4
M 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:
11 Cedar Crest Road,
Address
Salem MA 01970
City/Town State _ Zip Code
2. System Owner:
Glen Jordan
Name
11 Cedar Crest Road,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9783982958 x
Telephone Number
B. Pumping Record
1. Date of Pumping 01/18/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) U 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:
System not operating F4na High water leval Tight top sGlids Light bottom sludge
Main ttne el:eam. Nu fitter is pLe5ent oil tile tank, cuL.Eent Lank ts nut- designed LU
e used wit a i ter. Cover(s) secu--re-ff-. RecommenUeci Boost additive,CCLS a itive.
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
_ 01/18/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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