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System Pumping Record 10-5-17
RECEIVED 11/22/2017 11:56AM 9767450343 Salem Health Dept 2017-11-22 08:03 TRCT-Newtown 2034260067 >> 9787450343 P 2/10 Commonwealth of Massachusetts CityRown of�,~e t� System Pumping Record Form 4 DEP has provided this form for use by local Board$of Health.Other forma may bo used, but the Information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date In accordance with 310 CMR 15.351. A. Facility Information important:When Vft out tome 1. Syrstem Locatlowon it*oernpdw J� uaa only the taD key to move Your 74 ..... .. ._ ..._.. curaa•dnnot uas ..k ..... fi .. the return _ {ys '7 Q k Bfata _.... _. 7.Ip Coda ..._.. LL T1 2. System Owner tt n`C'. t� ..�l Pg Hama .... ......... ... _. . as ........... .......... ... State ._.... . ...... 7�eP one umtier B. Pumping Record 1. Date of Pumping ro�a. .L.I'I 2. Quantity Pumped': �.�, // Were3. component; Q Cesspool($) I -foptle Tank © Tight Tank g ❑ Grease Trap © Other(describe)' 4, Effluent Tee Filter present? 0 Yes L -900 tf yes,was It cleaned? ❑ Yes L+<o 5. Observed condition of component pumped: B. S tam Pump�e'd8 ; Noma Vemde LMaua Numbar, .. Wind.River Environmental 7. Location where contents were disposed: aignatura of NauPor - .. Data-. eipnatum of I( no izwi (or attach WIRY r+'wPt1 Nis tSPotm4,doc+11l12 system Pumping Macaw•Pago 1 of 1