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28 NORMAN STREET SMEA KEEPING YOU QRGA,N,IZED No. 10330 153L MUM= =m `( wm" CDNWIO%[jj c.mr'.ara uo m RrT-rnN MrA ' nonw MADE IN USA GET ORGAN IZED AT SMEAD.COM RECEIVED 10/06/2017 01:39PM 9787450343 Salem Health Dept 2017-10-06 09:39 TRCT-Newtown 2034260067 >> 9787450343 P 1/4 Commonwealth of Massachusetts " City/Town of � System Pumping Record Form d DEP has Provided thin form for use by local Boards of Health. Other forms may be used, but the l tormatlon must be substantially the Sams as that provided here. Before using this form,cheek with your local Board of Health to determine the farm 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 OMR 15.351. ._...__�_ -_....___�_— A. Facilit- 7y information - - _ Impmtsnt:When taorl out tomes 1, :System Location: M ire oomputer, 7 'R{/ ,,,,te.A use only the tab ..f-... ..Ft'0.rk'` .k .... 7d. .. .s...,.. ...... key to move YOU( AWraaa . Cursor-do not fCJ we the mtum '.. AAA key, Cftyt awn ..._., .. .. State rode - 2. 8 W Owner: Name _ Talep Oita Number B. Pumping Record 1_ j 1, Date of Pumping 2. Quantity Pumped: day , 6aliq 3. Component: n Cesspool($) ❑ Septic Tank CU40ght Tank [] Grease Trap © Other(describe): .—.11-1 .. . . I .,. ...., ,., .,... 4. Effluent Tee Filter present? C1 Yet M40 If yes,was it cleaned? © Yes Q<o~ 5 Observed condition of component pumped: bot. ... _...... . . _ & System Pumped B p y mo N7.1.2 OC:6 E �. NUmber Wind River Environmental Cpntparty 7. Location where contents were disposed: bkm MA. oturantHaWer ... ., trmto . . ... t5form4:doc 11112 SYSM111 pUmpMg ftkcofd•Ptipo i of 1