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90 ORNE STREET SYSTEM PUMPING RECORD 3-28-22 RECEIVED ICN Commonwealth of Massachusetts APR 19 2022 City/Town of salem CITY OF SALEM System Pumping Record BOARD OF HEALTH Form 4 � V 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 Fieam or diner approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 90 Orne Street, Address Salem MA 01970 City/Town State Zits Code 2. System Owner: Ed and Betsey Bennett _ Name 90 Orne Street Address(if different from location) Salem MA 01970 City/Town State Zip Code 5088435780 x Telephone Number B. Pumping Record 1. Date of Pumping 03/28/2022 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© No If yes, was it cleaned? ❑Yes ❑ No 5. Observed condition of component pumped: System Operating Fine Normal water level modg-�ate tQP snlids modQrate battom sludge. Both baffte5 aze- int:ctut. Matri tine No filtez ±5 present on Llie tanki current tank is not designed to be useck with a filter. Cover(s) secured. Removed 1000 gallons. Recommended Boost additive,CCLS additive. 6. System Pumped By: Robert Herrick Name Vehicle License Number Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752 Company 7. Location where contents were disposed: Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA _ 03/28/2022 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11112 System Pumping Record•Page 1 of 1