System Pumping Record 1-29-18 RECEIVED 02/16/2018 12:32PM 9787450343 Salem Health Dept
2018-02-16 08:27 TRCT-Newtown 2034260067 >> 9787450343 P 2/2
�. Commonwealth of Massachusetts
Cityrrown of ,5�/
System Pumping Record
1 71P Form 4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the
information must be substantially the some 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 authority within 14 days from the pumping date in
accordance with 310 CIVIR 1&381,
A. Facility information
Important:when
fill Out"a t, System Location;
use Mare tab
Ray to to move your Adtlre6e ...
th
cumth•do not (s."'Jtv^, MA
k
tea e netum OWTOWn
ey, - , state Yfp Code
2. System Owner:
Nnma
Nddrate(tf Mann from locaftri) ... .......
aty�own
_. . stet.0 _. Yip coda..,. _.
......-......_.�__,.. Telephone Number
..
B. Pumping Record
1. Date of Pumping oat/ `^ 14 - 2. Quantity Pumped: f
oarwrq
3, Component: ❑ Casspooi(s) [3 Septic Tank ❑ Tight Tank Grease Trap
0 Otherldascrlbe). _
4. Effluent Tee Filter present? [] Yes [A No If yes,was it cleaned? ❑ Yes El No
6. Observed condition of componeni pumped;
8. System Pumped By:
Name _ . . ..
Vahkta Ucanaa Number
Wind River Fnvironmentai
UbetiranY _
7. location whore oontants were disposarl:
tifgtiattua of Hama ... -. - Da1e
Signature of Receiving Falloy inrattaml raoilty racelpo nwe - -
t6fem74400-1 i/i?
System Pumpiry Renato•gaga t of t