The URL can be used to link to this page

23 CEDARCREST AVENUE SYSTEM PUMPING RECORD 2-26-18 RECEIVED 03/16/2018 10:42AM 9787450343 Salem Health Dept 2018-03-16 06:45 TRCT-Newtown 2034260067 >> 9787450343 P 2/3 Commonweal of Massachusetts tT City[Town of t'-N SYStem Pumping Record Form 4 DEP has provided this form for use by local Boards of Health,other forms may be used,but the information must be substantially the same as that provided here,Before using this form,check with your boa!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 C:MR 16,351, Important:when tilling out lomis 1. etem Lox anon: an the wmputer, (� (t uss Only theab `,-,.�'CC'tC ,.{ '.. ",... � .... key fo move your Marais cursor-do not _ �+ use he return CtlyfTmm .�. . '" - . MA key. State . . lip Cedw to Y. System t]wnoC Name AtIljj*A k(if State zip Caen S. .....•�.___.._.._........_�....W Trdephena r Numbe Pumping Record( ..4W _ 1. Date of PumpingDate+ � 2, Quantity Pumped: . sons 3. Component: Gesspooi(s) ,RiZeptic Tank 0 Tight Tank [3 Grease Trap rJ other(describe): 4, Effluent Tea Filter present? a © No If yes,was it cleaned? yea [3 No 6. observed condBbn of Inpollent pumped: 6. System Pumped By: cf( 2 Vaftiatd Llaermtl Number Wind River Environmental 7. Location where contents were osed: stgnatura of Mauler ... . . . .. _.... __ ..._. ... . .11 Signature at Receiving Facility lM atlach taGtlty reaalptj ._ pats....._ .. _ ... tefvmW.dao•i 111� Systom pumping Reaattl+page 1 of 1