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17 CROWDIS STREET wiversal, www.m universalo .com Y P phone:1-866 756-4676 UNV12110 MADE IN USA RECEIVED 10/06/2017 01:39PM 9787450343 Salem Health Dept 2017-10-06 09:39 TRCT-Newtown 2034260067 >> 9787450343 P 3/4 Commonwealth of Massachusetts City/Town of �(e� System Pumping Record ki't;� o Form 4 DEP has provided this form far use by local Boards of Health.Other forms may be used,but the information must be substantially the same as that provided hare. Before using this form,check with your baai 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 accardanca with 310 CMR 15,351, A. Facility Information " Imld"rit:whop tflOng out forms 1. System Location' use the only the er, `] use Mly tho tap � ( key to moo your Addy gg, j/ -7 J".. . .. Ubee Me return C "�(«jr�.":r'.' N, ..—..... ................... .MA, � /C,....a Cdy%Twun Y.ey. 3tato .. �� ....... Code 2. System Owner: Adclraa:pf dNFamnt from locetlaa) ." State ..... .. .,... . . .. ......,. __....-.,, __-,, (,C— .,,,,�,,...�___... ..�... TBlaphono N mbar M Pumping Record / 1. bate of pumping p ate• •. r a, Quantity Pumped: _. ©allano 3. Component © Cesspool ❑ Septic Tank [I Tight Tank - [] Graeae Trap Other(describe); 'JZ 1 I J .. :" .. ....... . ... . .. . 4, Effluent Tea Filter present? Yes-kNo it yes, was it droned? (] Yes j No S. Observed conditiOA ponent pumped: 8. Syste mpe y: Noma ...... ........ ........ ..... Vahtoie Lioanoe Numbbt Wind River Environmental GompawY ii 7. Location whore aim�tt wt disposed; TIN _�__ lr- '7 - lot for Dole s(gnatutenr RaGprvinp t3torm4.doo•19tt2 ayatam Pumping Racprd•pogo 1 of 1 02/12/2016 15: 06 9782814869 WINDRIVER PAGE 08/14 Commonwealth of Massachusetts Form A--System Pumping Record B eCLf�r' Massachusetts System Pumping Record System Owner Y System Location r,gutran ?lulls Primary Home 17 Crowd-in Strset 17 Crowdis Strost Salem, MA, 01970 Salon,' 44A, 01970 (791)-760-2615 x (781)- 760-3615 x Nguyen Winh Type; Emergen Routine C Cesspool: No Yes .cTank: No � Yes Dote of Pumping: -- L C Quantity Pumped: ��Q fl Gallons System Pumped Ry: Wind River Environmental.LLC permit#: Contents Transferred to: Contents Disposed at: r Date: Pumper Signature: :ondition of System/Other Comments �9 armme�aynmwar Dep Approved Form-12/07/95