System Pumping Record 10-26-17 RECEIVED 11/22/2017 11:56AM 9787450343 Salem Health Dept
2017-11-22 08:07 TROT-Newtown 2034260067 >> 9787450343 P 9/10
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System Pumping Record
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DEP has provided this form for use by local Boards of Health,Other forma may be 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 tine 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 MAR 15 361,
A. Facility information
rmportaM:When
riimg out f hyrs 1. System Location:
nn the computer,
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Ar"`11 2. SV*Ln Owner:
area
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erg i 514 ''317?
Telaphone Hunter
B. Pumping record ��v^� ---
1. Date of Pumping 2. Quantity Pumped: --
3. Component. i ] Cesspool(s) Septic Tank rl Tight Tank Grease Trap
[:) Other(describe):
4. Effluent lea Filter preseW ® Yes ( No if yes,was it cleaned? Yes Ca No
6, Observed condition of component pumped;.
6, System Pump�MBy:
Hems— . Vih4ra,Licanea Number
Wind River Environmental
company
7, Location where contents Were disposed:
Tpmwich, MA.
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