System Pumping Record 2-10-18 RECEIVED 03/16/2018 10:42AM 9767450343 Salem Health Dept
2018-03-16 06:45 TRCT-Newtown 2034260067 >> 9787450343 P 1/3
Commonwealth Of Massachusetts
City/Town of_;akm
System Pumping Record
Form 4 0 V� w!`
DEP has provided this form for use by local Boards of Health.Other forms may be used, but the
lnfo.mtatkm 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 authorky within tit days tram~the pumping date in
accordance with 310 CMR 1&$61,
A. FseilPty Inforrrtatian .-�---.__ ._._
important:Wh"
Nang out forme A System Location:
an the computer, Ci use only the tatr -a-Y1 C( ti/ ie. .
key m move your Address . • -
oumm -oorat /.y
We the ratum l l�C',M1 MA l,.-rf c, 3-0
xey. CdtylTawrr ... 5taie
$tF
2, System owner:
N�
Address Is dtserent trap IGOetldy
CiiyfTovm..... Z2ad
a. .
Stets
.,.,._.._.._.......____,_...,.._�_....,.__�.._. Tebplmne Number _
a. pumping Record
�{
1. Date of Pumping (Data4 P01.. - Z. 4uantlty Pumped: t
3 Component: [a CeSspooi(s) Septio Tank [] Tight Tank Grease Trap
Other(descrlbc);
4, Efftuont Tee Filter present? [3 Yes '-) No R yes,was it Cleaned? M Yes ❑ No
B. Observed condition of component pumped;
6, System Pum efBy:
Wind River Environmental
Company . ... _,. . . ._
7. Location where contents were disposed;
Signature of Haller -_.. ... ...
13lgnature of Rece oro iz r ltiy for attecdr rsaaty receipt). ... psTg"'r'a. - --._ ..
t8forma,dor $1M2
Bystom Pumpmo Record.Page t of t