23 GLENDALE STREET SYSTEM PUMPING RECORD 12-22-21 RECEIVED
�C\ Commonwealth of Massachusetts
MAR 212022
City/Town of Salem BOARD F EAMh!
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:
23 Glendale Street,
Address
Salem _ MA 01970
City/Town State Zip Code
2. System Owner:
The Fred J Dion Yacht Yard
Name
23 Glendale Street,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787676201 x
Telephone Number
B. Pumping Record
1. Date of Pumping 12/22/2021 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes 0 No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
Nn+ Applicable wa+ level Oi n bottom sludge gin t+Ap Rol ids Main line No-t
used with a fiIter. Cover(s) secured. No JrCL party paperwork > e . Removed 1
gallons.
6. System Pumped By:
Robert Herrick
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
12/22/2021
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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