11 TRADERS WAY SYSTEM PUMPING RECORD 7-12-22 RECEIVE®
Commonwealth of Massachusetts
SEP 2 9 2022
ALEM
City/Town of Salem CITY O HEAL
BOARD OF HEALTH
System Pumping Record
k.` 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:
11 Traders Way
Address
Salem MA 01970
City/Town State Zia Code
2. System Owner:
Shaw's Supermarket
Name
523 Spriniq Street
Address(if different from location)
East Bridgewater MA 02333
City/Town State Zip Code
5082692007 x _
Telephone Number
B. Pumping Record
1. Date of Pumping 07/12/2022 2. Quantity Pumped. 1000..0000 _
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank Grease Trap
Other(describe):
4. Effluent Tee Filter present? 11Yes ❑X No If yes,was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
Normal water le-al 4in bottom 211idge Wn tc�p sgiids Both baffles are intact
e used with a filter. Cover(s) secure . No Jrd party paperwork filled. Remove
1000 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:
163 Western Ave, Gloucester, MA 01930
07/12/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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