4 HILTON STREET SYSTEM PUMPING RECORD 3-7-22 RECEIVED
Commonwealth of Massachusetts APR 19 2022
City/Town of salem
CITY OF SALEM
mSPIN,a61System Pumping Record BOARD OF HEALTH
Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must be
snhstantially 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:
4 Hilton Street,
Address
Salem MA 01970
City/Town State Zig Code
2. System Owner:
DEBRA GAUVREAU
Name
4 Hilton Street,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9788150914 x
Telephone Number
B. Pumping Record
1. Date of Pumping 03/07/2022 2. Quantity Pumped. G000.o000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank ❑Tight Tank ❑Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑Yes L�J No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
SI'Stem opeL=ating Eine Normal water ]Q'TQI madezata top 2C]JdI2 Moderate bottom
current tank is not cLesigned to be used with a filter. Cover(s) secured. Pumped
1000 gallons. Recommended No Recommendation.
6. System Pumped By:
Marcus Lark
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
; 1•) 03/07/2022 _
Signature df Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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