SYSTEM PUMPING RECORD 10-18-17 RECEIVED 11/22/2017 11:56AM 9787450343 Salem Health Dept
2017-11-22 08:05 TRCT-Newtown 2034260067 >> 9787450343 P 5/10
Commonwealth of Massachusetts
City/Town of w�
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forma may be used, tnA 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 Raoord 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 15,361.
A. Facility Information
unpansrd:wt>en
H01%out form 1. System Loeatlo t
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2. systa Owner'
Name
state
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_ Tefephono hiUmt+er
S. Pumping Record y
1. Date of Pumping ._ 2, quantity Pumped;
t9a,,ilom,
3, Component,, Cesspool($) ❑ iSeptic Tank 0 Tight Tank ( Grease Trap
,9 Other(describe)' t/.
4. Effluent Tee Filter present? [] Yes [?�No it yes,was it Cleaned? Yes ❑ No
6. Observed condition of component pumped:
Nerve rnpad B
Wind River Environmental
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7. Location where Contents were disposed:
WWTP
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Bsidlord, Ms 01M
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t6fonn4.dw-11717, Systatn Pwmping Record•Pepe 1 at i