15 BRIDGE STREET SYSTEM PUMPING RECORD 6-2-22 Commonwealth of Massachusetts
RECEIVED
a City/Town of Salem JUL 15 2022
10 System Pumping Record CITY OF SALEM
Form 4 BOARD OF HEALTH
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:
15 Bridge Street
Address
Salem MA 01970
CityFrown State Zip Code
2. System Owner:
Ninety Nine Restaurant
Name
14A Gill Street,.
Address(if different from location)
Woburn MA 01801
City/Town State Zip Code
9783728203 x
Telephone Number
B. Pumping Record
1. Date of Pumping 06/02/2022 2. Quantity Pumped: 2000.0000
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? Yes No
5. Observed condition of component pumped:
:e used with a filter. Cover(s) secure . No Jro party paperwork filled. Remove
2000 gallons.
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:
NEMO Yard: 54 Knox Trail, Acton, MA 01720
06/02/2022 _
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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