10 BARNES AVENUE - SYSTEM PUMPING RECORDS AND D-BOX SPECS RECEIVED 06/16/2017 04:59PM 97137450343 Salem Health Dept
06/16/2017 16:52 9782814869 WINDRIVER PAGE 05/05
Commonwealtfjof Massachusetts
,
City/Town of w,
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
important:when
filling out forms 1. System Location:
on the computer, n
use only the tab �� �r"t� 5 Ave-
key to move your Addras
cursor-do note n
use
.
Y MA
ke the return Ciwrown State Tip Code
m
2, stem Owner:
Name
mn
Address(d different from location)
Clryfrown
Telephone Number CJJ
B. Pumping Record
1. Date of Pumping Data a 2. Quantity Pumped: I W
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? .r& Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By
Name vehicle License Number
Wind River Environmental
Company
7, Location where contents were disposed:
I.W.W.T.R
Signature of Hauler Dale IPSMch, M w
Signature of Receiving Facility(or attach facility receipt) Date t�it1
t5form4Aoc•11/12 System Pumping Record•Page 1 of 1
RECEIVED 04/11/2017 12:12PM 9787450343 Salem Health Dept
04/11/2017 12:04 9782814869 WINDRIVER PAGE 01/01
Commonwea o Massachusetts
City/Town of�7)
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
Important:When
filling out fors 1. System Location:
on the computer, Pry–only the tab 62
key to move your Address ' —
oWsor-do not MA 0�9 �r}
use the return CiryITow
key. State Zip Code
2. System ner.
m Qr.
Name
men
Address(if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat 2. Quantity Pumped: �Q
Gallons
3. Component: ❑ Cesspo6l(s) [ eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? E?Ye-s ❑ No If yes, was it cleaned? es ❑ No
5. Observed condition on of component pumped:
^
6. System P-uumspeedd By:
Name Vel clense N hart
Wind River Environmental
Company _ Wind River$nvironmentw
163 Western Ave.
7. Location where contents were disposed: w Glonoester,MA 01930
Ci
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5for4.doc-11/12 System Pumping Record-Page 1 of 1
RECEIVED 08/25/2016 02:02PM 9787450343 Salem Health Dept
08/25/2016 13:57 9782814869 WINDRIVER PAGE 01/03
69^.¢17tY�ttf6�, 05101!2000
Commonwealth of Massachusetts Form 4--System Pumping Record 62N%
Massachusetts
System Pumping Record
System Owner System Location
Torigan Carolyn Primary Home
10 Harness Avenue ' 10 Barnes Avenue>
Salem, MR, 01970 Salem., MR., 01970
(978)-745-1134 x (978)-745-1134,x
Torigan Cacolya
Type: Emergen Routine
Cesspool: No yes septic Tank: No Yes /
Date of Pumping; 6 ---.t - Quantity Pumped: D Gallons
System Pumped By: Wind River Environmental,LLC Permit it:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
i.W.W.T.P
1pmich, MA.
® � � Dep Approved Form-12/07/95
06/22/2015 23:52 9782814869 WINDRIVER PAGE 06/09
n'm7nRgnan
nFrnif�nnn
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
mp
System Pu in
y g Record
FBarnes
System Location
Carol, n Primary Home
venue 10 -Racnen Avenue
079;0S&]em, MA, 01970
34 x
Toricgan Carolyn
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping:
Quantity Pumped: 115 c,o� C,allons
System Pumped By: Wind River Environmentai,LLC Permit#:
Contents Transferred to:
:ontents Disposed at: Salem, MA,
)ate: Pumper Signature; v
:ondition of System/Other Comments
Pnn�Avo mcycied�,� Dep Approved Form-12/07/95
Commonwealth of.Wassachusetts
e City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,.4th Floor Mayor
SALEM,MA, 01970
DISPOSAL WORKS CONSTRUTION PERMIT
DATE PRINTED: 04/19/2012
ESTABLISHMENT NAME: Wind River Environmental, LLC
Fite Number:BHF-2002-000007 577 Main Street Suite 110
Hudson MA 01749
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permk Expires Fee Restrictions/Notes
Disposal works BHP-2012-0435 Apr 19,2012 Dec 31,2012 $180.00
construction
Total Fees;: $180.00
PERMIT EXPIRES December.31, 2012
Board of Health
Page 1
Commonwealth of Massachusetts
City/Town of Salem Number
Disposal System Construction Permit
Form 2A
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
the local Board of Health to determine the form they use.
Permission is hereby granted to:
Important:When
JOme � �a11ank \dine ►�- �vc� Enyt�on�nen � 1
filling out forms Name Name of Company
on the com uter
P
use only the tab I (of) Ayc
key to move your Address
cursor return not G i U ce Dyd Mcj
key. 2 �
use the retCity/Town V1 State Zip Code 7
to perform the following work on an on-site sewage disposal system:
I
� [�' REl onstruction
epair or replacement
❑ Repair or replacement of system components
ASL
Facility Address
5('A)l CM MA 0) C170
City/Town State Zip Code
Owner � Telephone Number
The work to be performed is further described in the Application for Disposal System Construction
Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions
or special conditions:
��,ycxl�� olcl l�r�-�ribu��Ur1 fox
m-Ao11 nPl�) box
CP 1 0 CwYl@Q. bUra C:AAl hnC ll)MN seheduW qo �-X
_()U�1C� 7- woo) wren 1I CA
All construction must be completed within three years of the date below.
pct ri t
Approved b Date
e a l~ti "QrA'1t k
Title
t5form2a.doc•06/03 Disposal System Construction Permit•Page 1 of 1
04/23;2012 12:43 9782814869 WINDPDER FACE 01!04
Wind River Environmental
April 23, 2012
Attn: Larry Ramdin
Please find attached a copy of the distribution box that was discussed
with Jim Gallant. If you have any questions please let me know. Jim can
also be reached at 978-580-0216,
Best regards,
Jamie Coble
Office Administrator
978-283-7315
163 Western Ave, Gloucester, Massachusetts 01930
ph 978-282-7315 fax 978-281-4869
e-mail jcoble@wrenvironmental.com
l o��
04/23/2012 12:43 9782814869 WINDRIVER PAGE 02'04
Septic System and Drainage Products from Tuf-Tite -Risers -Riser Lids -Drop Boxes - ... Page 1 of I
Septic and Drainage Products - Risers - Drop Boxes - Distribution
Boxes - Tank Seals - Riser Lids - Riser Adaper Rings - Boots and
Mandrels - Parking Bumpers
7HD2
7-Hole Distribution Box
- click any picture for a larger view
lip. Injection molded HDPE Distribution box accepts
Tuf-TiWs Box Fittings and Speed-Levelers"'"7HD2 7-Hole Distribution Box.Comes complete
with a lid and your choice of 9 fittings.
Lid is 16"x 16";
Box/s 14-112"tall;
There/s a 2"drop between inlet and outlets.
5 per carton, 50 per pallet.
FREE FREIGHT on full cartons.
Download the PDF Page
S-35 Seal(yellow)
for thin-wall pipe
50 per carton
0S-40 Seal (blue)
for Sch.40 pipe
50 per carton
P-10 Plug (orange)
for unused holes
50 per carton
Speed Leveler. Used to
equalize distribution box
flow, Optional, additional
cost.
Tuf-Tite Corporation-Drainage and Septic
Products
1200 Flex Court•Lake Zurich,IL 60047
800-382-7009.847-550-1011 -847-550-8004(fax)
sales@tuf-tite.com
http://www.tuf-tite.conV7hd2.html 4/23/2012
04/23/2012 12:43 9782814869 WINDRIVER PAGE 03/04
TUFTIT Mole Distdbubion,L T
Box
k 7a w � frpa �a grwwi au s� Tough Problem
Providing a simple,reliable,and
ennanent means for dividing septic
tank effluent llow.
TUF-TITE Solution
A strong,stable,parnnanent, -
non-corrosive Tut-Tae Distribution
sox,with a Tuf-Tito Speed.Leveler.'.
In each outlaL
5 ,
. I
r
s
, i
■ Injection molded HDPE
t K -
■ Non-corrosive
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■ Easy to level
In a septic environment,no other Snap-in pipe seals They're permanent Stackable Riser .
material can match High Density They're patented.Simply insert Unlike cement-based pipe Easily extend the top of the box
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of trouble-free service.Tuf-Tete through the flexible,polyethylene . crack or corrode In septic Stackable HDPE Risers interlock
Distribution Boxes are injection Tuf•Tite seal.Plpes fit watertight. conditions.They stay pliable firmly and accept a screw-on[Ind
molded,using only premium HDPE Installation couldn't be easier. and watertight permanently, or grate.
which contains no fillers or foam.
04/23/2012 12:43 9782814869 WINDRIVER PAuE 04/04
TUFTITE 7-Hole I 1 Box
t A _ �'Shr "e+;q'• ,rf_.. +�'r ,+. " , 9� ",6 ,� . �. : t "�.� y.
N
r c
e s
a
f .
INSTALLATION IS
JUST THIS SIMPLE "`
1. Position the Distributlon Box
on level virgin soil. h
Do not place box on a
concrete slab.
2. Install the inlet pipe and S "i �„ S-40
outlet pipes.Be sure the
bottoms of all pipes rest on
Virgin soil. yws P-10
3. Level the Distribution Box
and all pipes as needed.
4. Backfill the pipes to within Choice of Fittings Turf-rite Speed Leveler ra VerSatiI0 Options
two feet of the Distribution 5-35 Pipe Seal,for: Control the flow of effluent from Drain Grate Black 16"x 16"
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box,then backfill up to the ■SDR 35 ■ASTM 3034 insert a Speed Leveler into each Can be affixed to Box or Riser
top lid ridge. ■Thin Wall 111500 Lb.Crush outlet pipe.Rotate each Speed with 4 stainless corner screws.
5, Install and adjust Tuf-Tite S-40 Pipe Seal,for: Leveler sc the flow is distributed 6"Riser Stackable 16"x 16"
Speed Levelers. ■Schedule 40 as desired.Available for 3"or 4" HDPE Riser provides 6"
6, Place lid on the Distribution 0 4"Corrugated PVC pipe. elevation to the Box or Riser.
Box and finish backfilling. P-10 Plug,for unused holes Ribbed for added rlgldity.
w ;1., C`+:.! Water-tight
lids and Risers
oralnage and haptic Products, Tu6Tite'
rt pla�r`eu A ,
mUf-Td¢"GdnlOration
1200 Flex Court +i
Lake Zurich,Illinois 60047
J l�
m
ad1a99 OZ-3,
ir,USA
Farm mDz�3.adnled.n u5n
Ip Bci`ne5 Ave
Sctlern , MA 019-70
Fron
v�uaaiuu�mW�UBU�
Al
13aCK 8 24"
Ca5� iron a401 6G
Deck c O 4 Wxj `LXS'H R 5c( -Vo ISu
i000 c2al TANK 4 grade
,Sebe 4o aa.S
D O cove( on sur4bce, 3 rises o
Poiy-LOX
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A-c- = 3 b W
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A-
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CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR 1?ubl>tcHealth
Prevem.Pmmo4.Pmcect.
TEL. (978) 741-1800 Fax(978) 745-0343
KIMBERLEY DRISCOLL tramdin@salem.com salem.com
LARRY 1tAMDIN,RS/RE;1-IS,CI-IO,CP-FS
MAYOR HEALTH AGENT
April 25, 2012
Carolyn Torigian
10 Barnes Avenue
Salem, MA 01970
Dear Ms. Torigian,
RE: Distribution Box Replacement
The Salem Board of Health has reviewed the plans and documentation submitted per replacement of the Distribution
box for your onsite disposal system. Further we have inspected the installed D-Box and have found the replacement
/installation completed and in compliance with the requirements of Title V of the State Sanitary Code 310CMR15.00
Yours very truly,
Larry Ramdin RS/REHS, CHO, CP-FS
Health Agent
022203p476 05!01/2000
0%
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Torigan Carolyn Primary Home
10 Barnes Ave 10 Baraea Ave
Salem, MA, 01970 Salem, MA, 01970
(978)-745-1134 x (978)-745-1134 x
Torigan Carolyn
,Type: Emergent Routine
Cesspool: No �, Yes Septic Tank: No Yes
Date of Pumping: 3— 7 _ Quantity Pumped:/0007 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
e
Contents Dispos'e ����®
�i'ZJ11
�iTY OF SALEM n 1.
30ARD OF HEALTH
Date: Pumper Signature: 'e2'J.��
Condition of System/Other Comments j or le
® PfintMmo c aledpap r Dep Approved Form-12/07/95
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
5ysfem Owner• Yar
System Location
Torigan Carolyn Primary Home
10 Barnes Ave lu Barnes; Ave
Salem, MA, 01970 Salem, MA, 01970
(978)-745-1134 x (9'18)-745-1134 x
Tnriaan CArnl Vn
Type: Emergenc Routine
Cesspool: No ✓ Yes F Septic Tank: No Yes
Date of Pumping: 5-;Ro- 10 Quantity Pumped: 1000 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: -
Date: Pumper Signature:
Condition of System/Other Comments
1
a;meao�re�y�iwPaa — Dep Approved Form-12/07/95
f I
s
I yQ f♦O?O(VY9'i90 ASMi19M11 f
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
-_ - - , —. . .. .. . ......
System Owner' Sy stem Location
Torigan Carolyn Primary Home
10 Barnes Ave G -IN/SD 10 Barnes Ave
� ra �
Salem, MA, 01970 9 ° 2009 Salem, MA, 01970
(9'78)-745--1134 x puG (978)-745-1134 x
M Torigan Carolyn
Type: Emergent Gid 6(0V30A'1
Cesspool: No 50�Yes Septic Tank: No Yes ✓�
Date of Pumping: 6- '2'3-0'3 Quantity Pumped: /000 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: CC bb
AM A
I
Date: �/ Pumper Signature:
Condition of System/Other Comments
Oct
,n d
a.
Dep Approved Form-12/07/95
0222017938 001/2000
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
systlgaSy ` HomeornCarolyn imary
10 Barnes Ave 10 Barnes Ave
Salem, MA, 01970 Salem, MA, 01970
(978)-745-1134 x (978)-745-1134 x
Torigan Carolyn
Type: Emergency Routine
Cesspool: No Yes Septic Tank: NoI--1 Yes[Zo /
Date of Pumping: Quantity Pumped:(00 10 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: /��!D
\
Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved Form-12/07/95
0222013305 05MIrA00
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts /
System Pumping Record V`
System Owner System Location
Torigan Carolyn primary Nome
10 Barnes Ave 10 Barnes Ave
Salem, MA, 01870 Salem, MA, 91970
(978)-745 1134 x 19781 '745 1130 x
Torigan Carolyn
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: 'Z g'(� Quantity Pumped: 6&912 Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: SG S_ " )121 `
Date: Pumper Signature: /'CSV IIS
Condition of System/Other Comments
R .FIX
CITY OF SALEM
BOARD OF HEALTH 1 '
J
Dep Approved Form- 12/07/95
s
,1LM9/MIM
Commonwealth of Massachusetts Farm 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Labrecque Theresa Primary Home
3 Mckinlcy Rd 3 Mckinley Rd
Salem, MA, 01970 Salem, MA, 01970
(978)-744-•6977 x (978)-744-6977 x
Labrecque Theresa
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: U Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: I V - _`' Pumper Signature:
Condition of System/Other Comments
RECEIVED
Nov - 9 2008
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Form-12/07/95
lYlrlMA'a�nA �t�n�
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System owner' System Location
Labrecr{ue Carmen Primary Home
12 llayes Rd 12 Hayes Rd
Salem, MA, 01970 Sal€+m, MA, 01970
(1a18) -744 7336 x (973)—'144--7330 x
Labrerque carmen
Type: Emergen Routine /
Cesspool: No Yes Septic Tank: No Yes
Date of Pumping: Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date: 1 V `� Pumper Signature:
Condition of System/Other Comments
RECEIVED
NOV -g 2006
CITY OF SALEM
BOARD OF MATH
Dep Approved Form-12/07/95
Aonnni 17n 07�1fl1f7MY2
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Wendy's Restaurant Wendy s #861332
234 Littleton Road 6 Paradise Rd
Westford, MA, 01886 Salem, bIA, 01970
(80()) -443 -7266 x (978)-744-7800 x
Pd McDevitt
Type: Emergent Routine lav"S�
Cesspool: No /a Yes Septic Tank: No Yesl
Date of Pumping:
Quantity Pumped:__ Gallons
System Pumped By: Wind River Environmental,LLC Permit#: _
Contents Transferred to:
Contents Disposed at:
Date: I V Pumper Signature:
Condition of System/Other Comments
RECEIVED
Nov -g 2008
CITY OF SALEM
BOAR[) OF HEALTH
Dep Approved Form-12/07/95
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Wendy's Restaurant Wendy's 0862269
234 Littleton Road 91 Lafayette St
Westford, MA, 01886 Sulam, KA, 01970
(800)-443.-7266 x (978)-`745-x545 x
Type: Emergen Routine
Cesspool: No Yes c Tonk: No Yes
Date of Pumping: L
(} P Quantity Pumped:0000 Gallons
System Pumped By: Wind River Environmental,LLL Permit#:
Contents Transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
RECEIVE®
Nov -9 2008
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Form-12/07/95
Form 4 -- System Pumping Record
Commonwealth of Mossochusetss
Massachusetts
System Pumaro Record
System owner System Locution
Torigan Carolyn Primary Home
10 Barnes Ave 10 Barnes Ave
Salem, MA, 01970 S: lem, MA, 01970
(978) -745-1134 x (978) -745-1134 x
Torigan Carolyn
Type: Emergency Routine
Cesspool: No 5 Yes Septic tank: No F-Iyes
Date of Pumping: '+� �,� Quantity Pumped: /&&6 6alb .
System Pumped By: Wind Niner Environmental, LLC permit#:
Contents transferred to:
Contents Disposed at:
Date: Pumper Signature:
tura:
V
Condition of System/other Comments
NOV 112005 1
CITY OF SALEM
BOARD OF HEALTH
Dep Approved Form - 12/07/95
I
Farm 4 -- System Pumping Record
Commonwealth of Massachusetss
Massaclsnsetts
System Pumoino Record
System Owner System Lacotion
Toxi7riu 0,vol yn pr.im,.iry T?rne
j,1 Sflrllcz Ave A Simnel Ave .
Silem, M, (11970 5r.1-ria, P1A, O197^
,97S)_.74!i-. L34 n (g7(3J- 7g�-1'13; x
Type: Emergenry Routine
Cesspool: Mo (/ Yes Septic tank: w Yes Er
III
Date of Pumping: — Quantity Pumped: Gallons
System Pumped By: Wind IPiner amwimental LLC Permit#:
Contents transferred to:
Contents Disposed at:
Date_ Pumper Signature:
Condition of System/Ot cr Comments
Dep Approved Form - 12/07/95
L
FORM 4 -SYSTEM PUMPING kE_CpRD
CURRIER
SEPTIC & DRAIN SERVICE
If)?FOREST S'TREFT' 41IDDLETO;V,kf-A 0!949 a
978, 714 2772 s
ENVIRONMENTAL
r
/.a
CONtMI ONWBALTH Or MA8S%%C1 USETTS D �1iJY�
MASSACE[US) TTS
DEC 7 2000
SYSTEM PUMPING RECORD CITY OF SALEM
HEALTH DEPT.
r----
sYsreM 0wNSR sysrEna LOCATION:
(3t4
l) (2A�I��s Avg '
DATE OF PUMPING:, l( 7 bd QUANTITY YUMPED:� GALLONS
CESSPOOL: N`0 SEPTIC TANK: NO YES
SYSTEM PUNTED BYCURRIER SEPTIC & D�R4IN SERVICJE
CON'T'ENTS TR4NSFERR"nD T0:
DATE,__
�j X)—b �fNSPECTOR: !��°L4
i
FORM 4-SYSTEM PUMPING RECORD
URRIER
SEPTIC & DRAIN SERV C
17 FOREST STREET; MIDDLETON, MA 01949 ' 'WED
(978)(978) 774-2772
NOV 1 5 1999
CITY OF SALEM
/COMMONWEALTH OF MASSACHUSETTS HEALTH DEPT.
J Y MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER: SYSTEM LOCATION:
1�A�v`e S
� 4S-
DATE OF PUMPING: S c�
QUANTITY PUMPED: / GALLONS
CESSPOOL: NO YES 0 SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: DISI / INSPECTOR: Kc `l
107 Forest St. . . PPHN... FOMI 4 .SYSTEM PUMPING RECORD W\ a+s
Middleton, MA 01949 -
(508) 774.2772 SEQgfc V
�, Conunonwealth of-Massachusetts: 1998
Ica^ , Massachusetts
Dov s -
CITY OF SALEM .
HEALTH DEPT.
Svstem Pumping Record ,
j
stem 1�rrer ystem Locatlon
� D
Date of Pumping. � pG
Quantity Pumped: gallons
Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes
S%'stem Pumped by: CLvLt (e—&v, r
Contents transferred to: License #;
r:
Date
Inspector
J
• THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY•
j
107 Forest St. �N FORM 4 - SYSTEM PUMPING RECORD-
Middleton,MA 01949 IDV -
(508) 774-2772 SEP SE�*4
Commonwealth of Massachusetts
/ ? , Massachusetts NOV 1ti97
CITY OF Skt.c 't
HEALTH 11E?T.
Svste„____m_Pumping Record
stem ��ner� ystem.T ocauon—
Ire,
nam z
Date of Pumping: — /O Z2 A> QuantityPumped: "' m
. --gallons
Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes
System Pumped by:
License : ..
Contents transferred to:
Date
'f�L Inspector _ S
107 Forest St. ^ £ e t a gFQR1 l 4.- SYSTFA-1 PUMPING RECORD
I Middleton,MA 01949 � �^ , �'" „
...
(508) 774-2772 °'r
Sot
�onwealth of Massachusetts
. ,,,.. NOV 4 1996
Massachusetts
CITY OF SALEM
HEAL Tli DEPT.
A�Y
_. L QTY.
� '9y5fF.�. nn-� ecord
stem HTter w
ystem LopaUon
ac
10 8ar�.es Iwe
+
i
, Date of Pumping.
Quantity Pumped:/f gallons
j Cesspool: No ❑ > Yes r a."f
Septic Tanl,•F No ❑ Yes
SN stem Pumped by:
I Contents transferred to: License #!:
i�I nh
7
Date Inspector
I
.THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY •
06/12/2013 13:31 9782814869 WINDRIVER PAGE 131/02
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Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts0"
System Pumping Record
Syre&MI Owner System Location
iocigan Carolyn 1'rimacrf Bnme
10 BdlrTlss Asre 10 Barnes Ave
Salem, MA, 01970 Salem, MA, 01970
(976)-745-1134 x (9782-795••11.34 x
Type: Emergent Routine
Cesspool: No Yes Septic Tank: No yes�X
Date of Pumping: (f �� Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#i
Contents Transferred to:
Contents Disposed ot:
S.E.S.D
Salem, MA.
Date: _ Pumper Signature: }
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Condition of System/Other Comments
ENV RD NTAI
Drain Problems? We're Local&Fast
® ftmca on recycled paper Dep Approved F 1-666-866-6214
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