23 CEDARCREST AVENUE SYSTEM PUMPING RECORD 7-11-22 RECEIVED
Commonwealth of Massachusetts SEP 2 9 2022
City/Town of Salem CITY 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:
23 Cedarcrest Avenue,
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Peter Maitland
Name
23 Cedarcrest Avenue,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9783879998 x
Telephone Number
B. Pumping Record
1. Date of Pumping 07/11/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) Septic Tank ❑Tight Tank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑Yes R] No If yes,was it cleaned? ❑Yes ❑ No
5. Observed condition of component pumped:
designed to be used with a lilter. 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:
HaverHill Disposal Site: 40 s Porter St, Bradford, MA 01835
-=-- y 07/11/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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