15 CEDAR CREST ROAD SYSTEM PUMPING RECORD 6-8-22 RECEIVED
JUL 15 2022
Commonwealth of Massachusetts CITY OF SALEM
lay City/Town of Salem BOARD OF HEALTH
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:
15 Cedar Crest Road,
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
James Gattuso
Name
15 Cedar Crest Road,
Address(if different from location)
Salem MA _ 01970
City/Town State Zip Code
9786042491 x
Telephone Number
B. Pumping Record
1. Date of Pumping o6/08/2022 2. Quantity Pumped: 1000.0000
Date Gallons .
3. Component: Cesspool(s) E)(] 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:
Normal water ]@-a] Moderate top solids Moderate bgttam sludge Both baffles are
intac.;t. Main line Ciedr. Na f±Tt:eL ts yLe-sen.t on the tank; current tank is nut
designed to ..e use _ with a filter. Cover s secured. Recommended Boost
additive,Wind River Septic System Treatment additive.
6. System Pumped By:
Michael Graham
Name Vehicle License Number
Wind River Environmental, 46 Lizotte Drive, Suite 1000, Marlborough, MA 01752
Company
7. Location where contents were disposed:
Greater Lawrence Sanitary District : 240 Charles Street , North Andover, MA
06/08/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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