28 CHERRY HILL AVENUE SYSTEM PUMPING RECORD 5-2-22 RECEIVE®
Commonwealth of Massachusetts JUL 0 5 2022
it City/Town of Salem CITY OF SALEM
BOARD OF HEALTH
_ 1 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:
28 CherrV Hill Avenue,
Address
Salem MA 01970
City/Town State Zit Code
2. System Owner:
Terry_Aver
Name
28 Cherry Hill Avenue,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
6172400262 x
Telephone Number
B. Pumping Record
1. Date of Pumping 05/02/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) 0 Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? �Yes No
5. Observed condition of component pumped:
System Operating Fine Normal water level- moderate top galids- modarata bQttom
cleaned as needed. Cover(s) secured. Pumpe==gallons. Recommended Boost
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
05/02/2022 _
Sit nature of-Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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