15 BRIDGE STREET SYSTEM PUMPING RECORD 9-7-22 RECEIVED
O C T 14 2022
Commonwealth of Massachusetts
7 City/Town of Salem OF SALEM
BOAR 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:
15 Bridge Street
Address
Salem MA 01970
City/Town State Zip Code
2. System Owner:
NinetV Nine Restaurant
Name
14A Gill Street
Address(if different from location)
Woburn MA 01801
City/Town State Zip Code
9783728203 x
Telephone Number
B. Pumping Record
1. Date of Pumping 09/07/2022 2. Quantity Pumped. 2000.0000
Date Gallons
3. Component: ❑ Cesspool(s) Fjyj 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:
Normal water level J�n bottom sl-udge iiiz tGp ggiids Both baffles are intart
be used with a filter. Cover(s) secured. No Jrd party paperwork filled. Pumped 200.0
gallons.
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:
South essex sewerage district: 50 Fort Ave, Po Box 989, Salem , MA 01970
09/07/2022
Sidnature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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