1 DIPIETRO AVENUE SYSTEM PUMPING RECORD 9-21-22 RECEIVED
<C'-\ Commonwealth of Massachusetts OCT 14 2022
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:
1 Dipietro Avenue,
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
Susan Spinale
Name
1 Dipietro Avenue,
Address(if different from location)
Salem MA 01970
City/Town State Zip Code
6177210395 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/21/2022 2. Quantity Pumped: 1000.0000
Date Gallons
3. Component: Cesspool(s) Fj-(] Septic Tank ❑Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes ❑X No If yes,was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
S�'Stgm Operating Fing Normal water le"GI MQdeLatQ top so]-ids- Moderate bottom
current tank is not designed. to be used with a filter. Cover(s) secured. Pumped
1000 gallons. Recommended No Recommendation.
6. System Pumped By:
Marcus Lark
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
09/21/2022
Signa ure of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1