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System pumping record 2-28-18 RECEIVED 03/16/2018 10:42AM 9787450343 Salem Health Dept 2018-03-16 06:46 TRCT-Newtown 2034260067 >> 9787450343 P 3/3 Commonwealth of Massachusetts City/Town of System Pumping Record Farm 4 DEP has provided this form for use by local Boards of Health,Other forme may be used, but the Information must be substantially the samo as that provided here,Bofors using this form,check Wth 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 16.351, A. Facility Important:When tilling out rcrms 1. System Location. on it*computer, on only the teh _{ •�fl U . ] !.. key to move your Address - .... .. Omar-del not use the ratumR.� Y . MA key. utymwm - State.. _ Zip code 2< System Owner; Name `P _ AddrM(If dWerant from iocatiarq State -gyp Xlp C+CYda B. Pumping Record 1. Date of Pumping ' -/67 2, quantity Pumped: c? .. C9aiiana 3, Component; 0 Cesspool($) M Septic Tank ❑ Tight Tank f21,Grease Trap r,1 Other(describa); 4. rifivant Tee Filter present? © Yes No if yea,was it cleaned? [] Yes © No 5. Observed condition of component pumpod: 8. System Pumped By: Name _. . VahlrAo MMensa Ntdnber -_.. _ Wind River Environmental 7. Location where contents were disposed: ' :igrnaPu+s of Hautar Data so.eturo at Racei4ig Facility(dr adach faaky recafpt) t pate --_ .....,. . ... .. tatalm4tluo•t t112 System Pumping Record+Page !of 1