2 WYMAN STREET 4-26-22 SYSTEM PUMPING RECORD RECEIVE®
Commonwealth of Massachusetts
JUL o 5 2022
City/Town of Salem CITY OF BOARDof M HEALTH
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:
2 Wyman Street
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Susan Lowell
Name
2 Wyman Street,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9784309750 x
Telephone Number
B. Pumping Record
1. Date of Pumping 04/26/2022 2. Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) [-X-] Septic Tank Tight Tank ❑Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? Yes❑X No If yes,was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
Sj,stem Operating Fine Nc)rmal water laval Ddc�derate tGp solids Moderate bott=
current tan.k is not designed to be used with a tilter. Cover(s) secured. Pumped
1500gallons. Recommended Boost additive,CCLS additive.
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
04/26/2022
Signature o`f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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