220 HIGHLAND AVENUE 5-2-22 SYSTEM PUMPING RECORD RECEIVED
Commonwealth of Massachusetts JUL 0 5 2022
City/Town of CITY OF SALEM
Salem BOARD OF HEALTH
s' System Pumping Record
YJ
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:
220 Highland Avenue _
Address
Salem MA 01970
City/Town State _ Zia Code
2. System Owner:
Tropical Products
Name
220 Highland Avenue,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787405665 x104
Telephone Number
B. Pumping Record
1. Date of Pumping 05/02/2022 2. Quantity Pumped: 2500.0000
Date Gallons
3. Component: Cesspool(s) N] Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes Z No If yes, was it cleaned? Yes No
5. Observed condition of component pumped:
Normal watar level 2JP hattc)g sludge lin tap solids -Both baffles @rQ iptact
wed with a filter. Cover(s) secured. No 3rd party paperwork filled. Pumpe
gallons.
6. System Pumped By:
Marcus Lark
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, NIA 01752
Company
7. Location where contents were disposed:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
;^ 05/02/2022
gture of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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