1 DIPIETRO AVENUE SYSTEM PUMPING RECORD 6-10-22 RECEIVED
<L\ Commonwealth of Massachusetts JUL 15 2022
City/Town of Salem CITY OF SALEM
System Pumping Record BOARD OF HEALTH
Form 4
y 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:
1 Dipietro_ Avenue,
Address
Salem MA 01970
City/Town State _ Zia Code
2. System Owner:
Susan Sginale
Name
1 Dilpietro Avenue,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
6177210395 x
Telephone Number
B. Pumping Record
1. Date of Pumping 06/10/2022 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? 0 Yes No
5. Observed condition of component pumped:
Nnrzmal wat-r levQ1- Moderate tQP Solids- Moderate bQttom sludge Both baffles are-
Cesigned to be used with a tilter. Cover(s) secure . Recommen ed Boost
additive,Wind River Septic System Treatment additive.
6. System Pumped By:
Michael Graham
Name vehicle License Number
Wind River Environmental, 46 Lizo_tte Drive, Suite 1000, Marlborough, MA 01752
Company
7 Location where contents were disposed:
Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA
06/10/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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