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1 ELEANOR ROAD SYSTEM PUMPING RECORD 6-11-22 RECEIVED �L\ Commonwealth of Massachusetts JUL 15 2022 City/Town of Salem ,,' System Pumping Record CITY OF SALENI .. Y p� g BOARD OF HEALTH Form 4 M 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 Eleanor Road Address Salem MA 01970 City/Town State _ Zip Code 2. System Owner: Brian Martinez Name 1 Eleanor Road, Address(if different from location) Salem MA 01970 City/Town State Zip Code 6177087053 x Telephone Number B. Pumping Record 1. Date of Pumping 06/11/2022 2. Quantity Pumped- 1500.0000 Date Gallons 3. Component: ❑ Cesspool(s) Septic Tank Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? © Yes ❑ No If yes,was it cleaned? ®YesEj No 5. Observed condition of component pumped: System Ope-ating Eine Normal water I-euel- MQderate tGp solids Moderate battam siudge. Butli bafftes aie intact. Main 1±iie Clea.L. Filte-L ±s present and 11cas been cleaned as needed. over s secured. Remove 0 gallons. Recommended Boost additive,Wind River Septic System Treatment additive,. 6. System Pumped By: Robert Herrick Name Vehicle License Number Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborouh, MA 01752 Company 7. Location where contents were disposed: NEMO Yard: 54 Knox Trail, Acton, MA 01720 06/11/2022 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc°11/12 System Pumping Record-Page 1 of 1