220 HIGHLAND AVENUE SYSTEM PUMPING RECORD 8-25-22 RECEIVED
Commonwealth of Massachusetts SEP 2 9 2022
=i City/Town ofOR.
salem
System Pumping Record CITY OF SALEM
Form 4 BOARD OF HEALTH
TN
k V-rj 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:
220 Highland Avenue
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
- Tropical Products
Name
220 Highland Avenue
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787405665 x104
Telephone Number
B. Pumping Record
1. Date of Pumping 08/25/2022 2. Quantity Pumped: 2500.0000
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank Tight Tank ❑Grease Trap
Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes, was it cleaned? ❑Yes No
5. Observed condition of component pumped:
M&in Itne etear. No fttter t3 prescz�nt on tile tank; cuiLent tank can be outfitted
with a filter. Cover(s) secured. No 3rd party paperwork filled.
6. System Pumped By:
James Pepin
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
08/25/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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