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System pumping record 10-18-17
RECEIVED 11/22/2017 11:56AM 9787450343 Salem Health Dept 2017-11 -22 08:05 TROT-Newtown 2034260067 >> 9787450343 P 6/10 Commonwealth of Massachusetts City/Town of system Pumping Record Form A DEP has provided this form for use by 10001 Boards of Health,Other forms may be used, but the information must be substantially the saints as that provided here,Before using thin form,check with your local Board of Health to determine the form they use,The System pumping Record most be submitted to the local Board of Health or other approving authority within 14 days front the pumping date in accordance with 310 CZAR 16.361, A. Facility information _ ImponerH:Whert going out fame 1. System Location: on the computer, Ube only the tab key to move Your Cursor,do net A cv �v^y ,.c, ube the retUm Gtytlatir ..`" f•'-,J.. ....__.. MA _6 l41. . key. aloud 7dp Cade 2, System Owner. Noma hdtlrasx{I/dNffront from looetlan) CIfY/Town state 21p Coda . . ....... _ _ TmiethanoWnW ....... B. Pumping Record �7 1. Date of Pumping Gieta M .. .. 2, Quantity pumped: - ..-.. arwions 3. Component: ❑ Cessp00l(6) ❑ Septic Tank [I Tight Tank rl Grease Trap 91.Other(describe): fl c' r . _ _. 4. Effluent Tee Filter present? [] Yes 10 NO if yes, wee It cleaned? 0 Yes © No & Observed condition of coDWnent pumped: S. System Pumped Sy; Name _ _. .... VON aM Ltrenae NUttibar Wind Rlyer gnvWwrnentai txarrpeay _. . .. .. .... ..... T Location WbOre contents were disposed: aipnatw®of Mauler .. ♦7� ,�5 q ..... . � ..S. SltpuWrootRa0aiVingpacyllty{aradachfidWt wce�ty... Ciao... 2341ft* . tsiamw dod 1 Ut2 Syetorn pumping Record Page 1 ot i