15 BRIDGE STREET SYSTEM PUMPING RECORD 12-14-21 Commonwealth of Massachusetts
a City/Town of Salem
System Pumping Record
Form 4
a'
M •y5'. 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.Th v System Pumping Record must.be subinittud to the local Board of Health or othe[ approving authurity within 14
days from the pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
15 Bridge Street _
Address
Salem MA 01970
City/Town State _ Zip Code
2. System Owner:
Phil Gagne Ninety Nine Restaurant
Name
14A Gill Street.
Address(if different from location)
Woburn MA 01801
City/Town State Zip Code
8664618372 x4
Telephone Number
B. Pumping Record
1. Date of Pumping 12/14/2021 2. Quantity Pumped: 2000.0000
Date Gallons
3. Component: Cesspool(s) ® Septic Tank Tight Tank R Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes Z No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
e used with a i ter. Cover(s) secured. No r party paperwork fi e Pumped
gallons.
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:
South essex sewerage district: 50 Fort Ave, Po Box 989, Salem MA 01970
12/14/2021
Sign4d-re of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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