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System Pumping Record 10-25-17 RECEIVED 11/22/2017 11:56AM 9787450343 Salem Health Dept 2017-11-22 08:06 TRCT-Newtown 2034260067 >> 9787450343 P 8/10 eommom City/Town of 1 System Pumping Record Form 4 DEP has provided this torm for use by local Boards of Wealth,Other forms may be used, but the information must be substantially the same as that provided hare, Before using this term,check with your local Board of Wealth 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 to accordance with 310 CMR 16,351, A. Facility information hen fl mil cow foponaft rms s 1. S L ygiEm r an ft oore Wier, use only fie to ....._...L...- ......,..,....,.......,.,«......-.,.................... ,._.......w...w..-..,...r........_._.,..... Hay to move your Addras Cursor.do not usethe return �.... S✓..L..d..s,,.__...............,....,..,,.�..».....».. MA...._r_:.....__..,_.__ tG! l key Cuy+Town state 2. Sys t5vrner; fiddresr wdHtsnnt earn��own)._....___...,..,.__m.._._...___^._.,�..,.......,.......�....................�..,,.._........-._._-... Gitylrawn.._.. ,_.._._._._..._....._....�.._._..-_.._..M.,.»- state 2ipG Telephone Number B. Pumping Record 1. Data of Pumping Coate-2j / 0uantity Pumped: oA) - — 3. Component © Cesspdoi(s) t' Septic Tank rj Tight Tank [j Crease Trap 0 Other(describe): _ _.. �....._.. 4, Effluent Tee Filter present? 0 Yes�No If yes,was it cleaned? [ Yea (j No 5. Observed ccyond' ' n of component Pumped: B. Systeriver ped 1.44 ° Nomavans Lcainae NumberWindnvironmental Campeny .......�..._�...__......__. .,.Y,______.„„.�........._v._. 7. Laoet)on where contents were disposed: Slpnatura�o" au._V. _._... ..,.... Ds� ...- ...._.....,,...._..,,„....._,.�..,_..._...�. Bop t ra of Racelvinp Feci7ltY for atisch facility Ma pt) Date ....._ ......,.„._.._...._..._. _._-...,...n..,w......_..._......_._.._. trrfornW,doc•11112 0ystam pwnp)ag Room page 1 of i