334 HIGHLAND AVENUE SYSTEM PUMPING RECORD 7-8-22 RECEIVE®
Commonwealth of Massachusetts SEP 2 9 2022
City/Town of
y 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:
334 Highland Avenue,
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Richard Lacha elle
Name
334 Highland Avenue.
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
9787445076 x _
Telephone Number
B. Pumping Record
1. Date of Pumping 07/08/2022 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 2] No If yes,was it cleaned? Yes No
5. Observed condition of component pumped:
System UpQa�ating Fine Normal water -level Light top sQ!id2- Ddodgr2ta bottc=
current tank is not designed to be used with a filter. Cover s secured. Remove
1000 gallons. Recommended No Recommendation.
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
07/08/2022
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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