System Pumping Record 11-20-17 RECEIVED 12/19/2017 04:09PM 9787450343 Salem Health Dept
2017-12-19 12:07 TRCT-Newtown 2034260067 >> 9787450343 P 2/2
ISomM4nawetliN W*4
City/Town of
System Pumping Record
Porn 4
DEP has provided this farm for use by local Boards of Health. Other farms may be used, but the
nformation must be substantially the same as that provided hare, Before using this form,check veldt your
theal Board sat of lthHo It tlorermine the farm they use, The System Pumping Record must be submitted to
the foam Board of Health or other approving authority within 14 days from the pumping date in
aacordenCe with 39t7 CMR 1ti 361.
A. Facility Inforrrtatinn
lmpat}amt:when
11 npautkamtt 1, SystemLocatkan:
on the etmputer, r1
use oniy the tab -1 q Ft Y^ /�„✓j
key to mwve yaur ArJCrtlea .. ".•..—..`^"'�-'.^� KK.--.,...,---- -
taraar-as nal / ...........—....�....••.•.«...._.........__,......,,»..._.._........
use the return /.�i..'. ._...,......._..._.�.......,.._..._._....�_ MA G'f
key.
stae
2. System Owner:
Naina`i-�tCivV+,d ..��_..._.._... . .._.._._.._..,_._._..M.... ..._...., ....W.._._......__....,�__....._.
TaMpharn 8, Numlkwt
1. Date of Pumping Gets f- -.-.�... 2. Quantity Pumpad: 1
c�albna
3. Component: [� Cesapoal(s) M Septic Tank Tight Tank [] Grease Trap
L� Other(describe):
4, Effluent Tea Filter prevent? ® Yes ® No If yes,was It cleaned? ® Yea [ No
5. Observed Condition of component pumped:
8, System Pumped Sy:
SL.J ._..�_..,......_..-
Wind giver Enviro thentst Yehiaia ika ao Numtmr
7. Location where contents were disposed.
stdm•+ure eft+eutai......�............._....._. 1 1�J W'1"1�
3� 110WatRece 1pB4yici1} MA,
kw
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System Pumatng PAWrd papa t W 1