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07/18/2013 11:42 9782814869 WINDRIVER PAGE 02/OR
Commonwealth of Massachusetts Form 4--System Pumping Record
Massachusetts
System Pumping Record
System Owner System Location
Shaw's Corporat x/Constant Flow IDwp - Shatr"s 87493
523 Spring Strc '' ,; . 293 Highland Avenue
East Bridgewater., IIA 02333 Salem, MA, 01970
(.508)-930-8272 x (978)-741-8660 x
Manager
Type: EmerganqL I Routine
Cesspool: No � G: Yes Tank: No Yes�
Date of Pumping'1)1:3 Quantity Pumped:_Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at: �} c
Date: q3 Pump o ure:
Condition of System/Other Comments
bep Approved Form-12/07/95
01/10/2013 12:54 9782814869 WINDRIVER PAGE 03/04
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Commonwealth of Massachusetts Form 4--System Pumping Record 126G°do
Massachusetts
System Pumping Record
System Owner System Location
Shaw's Corporation/Constant Flow IDWP - Shaw's #7493
523 Spring Street 293 Highland Avenue
Haot Bridgewater, MA, 02333 Salem, MA, 01970
(508)-930-8272 x (978)-741-8660 x
Manager
Type: Emergency
Routine
Cesspool: No Yes Seplirsank: No Yes
Date of Pumping: C, �'] Quantity Pumped: WO Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to: �I
Contents Disposed at;
Date: Pumcive; ,gnature.
Condition of System/Other Comments
i
® Pnn�eOon�crydMpe(u Dep Approved Form-12/07/95 -- — _ --- --
01/10/2014 14:58 9782814869 WINDRIVER PAGE 02/64
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Commonwealth of Massachusetts Form 4--System Pumping Record%G%
Massachusetts
System Pumping Record
I System Owner System Location
Shaw's Corporation/constant Flow IDTOP - Shawls 07493
523 Spring Street �e 293 Highland Avenue
wast bridggewatec,` NA, 02333"'. Salem, MA, 01970
(508) -930-8272 x (978)-741-0660 x
hlanagec
Type: Emergent Routine C-�
Cesspool: No Yes GTerk No Yes
Date of Pumping: /�-5"73
Quantity Pumped:Z-42z' Cellons
System Pumped 8y: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
)ate: Pumper Signature:
:ondition of System/Other Comments
rain¢aanmcyc�enpunce Dep Approved Form-12/07/95
02/12/2016 15:06 9782814869 {JINDRIVER. PAGE 13/14
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Commonwealth of Massachusetts Form 4--System Pumping Record 8160%
Massachusetts
System Pumping Record n
System Owner System Location
Shacr's Corporation/Constant Flow 109P - Shaw's #7493
523 Spring Street 293 Highland Avenue
Ea2t Bridclewater, MA, 02333 Salem, MA, 01.970
(50Q)-930-527: x (978)-711-B660 s
Manage:
Type: Emergen Routine
&M ss._
Cesspool: No Yes 5erta Tank: No Yes'—'
Date of Pumping: Quantity Pumped: Gallons
System Pumped By: Wind River Environmental,LLC Permit#:
Contents Transferred to:
Contents Disposed at:
Date! Pumper Signature: / Pr
Condition of System/Other Comments
® P(IflCdanrceyxlc�yaper Dep Approved Form-12/07/95
RECEIVED 08/10/2017 07:00PM 9787450343 Salem Health Dept
08/10/2017 18:52 9782814869 WINDRIVER PAGE 01/01
v"\ Commonwealth f Massachusetts
_ City/Town of
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
Important:When
filling out forts 1. System Location: //
on the computer, ��' {r
use only the tab ��y �� Ik(/� �
key to move your Address
cursor not
ret
use the return6WIll MA 0/r/7p
Ci !Town
key. ry State Zip Coda
J —h 2. System Owner:
w
S�ru/S
(mow^rII Name
Address(if different from location)
City/Tom State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D7ate 17 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ®' Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition f component pumped:
�s�
6. System Pumped By;
/n jGe
Name Vehicle Ucense Number
Wind River Environmental
Company
7. Location where contents were disposed:
1`A
Signature of Hauler Date }
Signature of Receiving Facility(or attach facility receipt) Date •+YJw
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