10 WYMAN DRIVE SYSTEM PUMPING RECORD 8-2-22 RECEIVED
Commonwealth of Massachusetts SEP 2 9 2022
ni City/Town of Salem CITY OF SALEM
System Pumping Record BOARD OF HEALTH
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:
10 Wyman Dr,
Address
Salem MA 01970
City/Town State Zip Cod
2. System Owner:
Alexia Meechin
Name
10 Wyman Dr
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9782106371 x
Telephone Number
B. Pumping Record
1. Date of Pumping 08/02/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: ❑ Cesspool(s) ❑X Septic Tank ❑Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑x Yes ❑ No If yes, was it cleaned? 0 Yes ❑ No
5. Observed condition of component pumped:
Normal water le-al Hgavy top so!irgs- MoclQrate battam s1lidge Both baff]--
secured. Removed IDOU gallons. Recommended Boost a ditive,Wind River Septic System
Treatment additive.
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:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
08/02/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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