28 CHERRY HILL AVENUE SYSTEM PUMPING RECORD 11-10-17 RECEIVED 11/22/2017 11:56AM 9787450343 Salem Health Dept
2017-11-22 08:07 TROT-Newtown 2034260067 >> 9787450343 P 10/10
Commonweaith"of Massachusetts
City/Town of 69te4+.t.
System Pumping Record
Form 4
DER has provtded this form for use by local Boards of Health.Other forms may be used,but the
infdrmabon must be substantially the same as that provided tiara. Before using this fonni,CrWk wrtn yGa
ticcal Board of Health to datarmine the form they use. The System Pumping Record must be submitted u:
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 lnforma � "-"""� '�
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System Owner:
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B> Pumping Record�. __ _
1 Data of Pumping I�tOL�� + y, Quantity Pumpay; I COO
a`aiau"
3 Camppnent; C1 cosswo)(s) 144pbc Tank Q Tight Tank C1 GraAsa tr4D
Other tdaasnbs).
4 Effluent Tee Filter pn4aant? a Yes M-4Qp if yea,was it cleaned? L;J Yes Ll No
5 Observed condition of component pumped
6 Sys Ptrmpaid By
Vitriede 1.riania gambit
and River Environme,Environmental
't Lor�tian whet' nt 9 were dr4poseJ.
noturatrtM�me
iynsUiri ct piiafivfiy faesiy tnr icueb heiaY MwWti