4 ELEANOR ROAD 4-15-22 SYSTEM PUMPING RECORD RECEIVED
Commonwealth of Massachusetts
a City/Town of SalemNA
JUL 0 5 2022
System Pumping Record CITY OF SA Form 4 BOARD OrHEAALLTH
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 submited 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 Eleanor Road
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Kathleen And Eric Thomas and Martin
Name
4 Eleanor Road
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787445343
Telephone Number
B. Pumping Record
1. Date of Pumping 04/15/2022 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 0 No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
System Ope-ating Fi;4e Normal watzer leval Moderate top solid2 Moderate battnm
current tank is not designed to e used wit-i a filter. Covers) secured.
Recommended Boost additive,CCLS additive.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
T Location where contents were disposed:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
04/15/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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