10 SALT WALL LANE 5-14-22 SYSTEM PUMPING RECORD RECEIVE®
Commonwealth of Massachusetts JUL 0 5 2022
City/Town of Salem CITY OF SALEM
System 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
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:
10 Salt Wall lane, _
Address
Salem _ MA 01970
City/Town State Zip Code
2. System Owner:
Vivian Cone
Name
10 Salt Wall lane,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9783146264 x
Telephone Number
B. Pumping Record
1. Date of Pumping 05/14/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: cesspool(s) ❑ Septic Tank ❑Tight Tank Grease Trap
X Other{deSCribe): Not Applicable
4. Effluent Tee Filter present? Yes 0 No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
System not Operating Fine udcjh water laval Liglit top sQlids Ldght bottom sludge-
e-used a filter. Cover s secured. Repairs needed: Pump needs replacement.
Owner to handle has her own pump co. Recommended Pump Repairs.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
163 Western Ave, Gloucester, MA 01930
05/14/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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