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System Pumping Record 12-21-17 RECEIVED 12/29/2017 09:04AM 9787450343 Salem Health Dept 2017-12-29 05:08 TRCT-Newtown 2034260067 >> 9787450343 P 1/1 Commonwealth of Massachusetts X City/Town of y�1 System Pumping Record Form 4 DEP has provided this form for use by lot:ai Boards of Health.Other forma may be used,but the Information must be substantially the same as that provided hers. Before using this form,check with your [owl 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 aoeordence wHh 310 CMR 15,351. A. Faciti#y Inffarrrtatitan — — bnpmunt:When fllWv dut forms I. System Location: Use only the tab , .. ay to move year m*ees /e*iA use eam 60 1"Irlt MA key,tns rstum Qlyrroem ..._ .._ .. . key, Y 3retb .. ZIP cads 2, System Owner xerr Address fif different from location) _ . ... .......-_ ....._.. .. .. statap p - ZfpCode . . . Tetspfione Num6w B. Pumping Record 1, Date of Pumping ne .•} 2. quantity Pumped: aaliorts 3. Component: rl Cesspaoi(s) C] Septa Tank ❑ Tight Tank Q!�Grease Trap © Other(dasoribe): 4. Effluent Tarr Fitter present? C] 'Yes M No If yes,was it cleaned? 0 yes n No 6. Observed condition of component pumped: 6. System Pumped By;. Name .- -- ..... .._ Vehicle License Number Compeny Wind River Environmental _ -. .... 7. Location where contents were disposed: ftignature of Houier . .. 4:. C1aln 91pnsWre W Raceivin Fad. �.g Data 15twmCdoo•t1/42 System Pumping Record Page 1 of t