SYSTEM PUMPING RECORD 4-22-22 RECEIVED
J U L 0 5 2022
Commonwealth of Massachusetts
lay w� City/Town of CITY OF SALPVi
Y Salem BOARD OF 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:
14 Cedar View Street.,
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Grace Lamarre
Name
14 Cedar View Street, _
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787452295 x
Telephone Number
B. Pumping Record
1. Date of Pumping 04/22/2022 — 2 Quantity Pumped: 1500.0000
Date Gallons
3. Component: Cesspool(s) ❑J( 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:
Sj,stem Operating Fine Normal water Ievel__ Moderate top Solids mnderate hQttom
current tank is not designedto be used with a filter. over s secured. Removed
1500 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:
South essex sewerage district: 50 Fort Ave, Po Box 989, Salem , MA 01970
r' 04/22/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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