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System Pumping Record 1-25-18 RECEIVED 02/16/2018 12:32PM 978745@343 Salem Health Dept 2018-02-16 08:27 TRCT-Newtown 2034260067 >> 9787450343 P 1/2 Commonweaftp of Massachusetts City/Town of System Pumping Record X Form 4 DEP has provided this form for use by local Boards of Health.tither forms may be used,but the information must be substantially that 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 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 CMR 16.361, A. Facility information hrlPwtam:Wnen sung outformw 1. $WterALocatio on the oompular, use only Iha ta0 key lo move{aur Atltl do not Dlty!'rdwn . ....... $Nte uae Ufa return IN y''"• MA V"the . ._.. key. 4W—A 2. Syste Owner: 6kame Atk(rM(if dlfforentfrom k cArten) - .. _. .. .. - Telephone Number .. .. S. Pumping Record(' �5 (}`y�� 1. Date of Pumping jao l�2, Quantity Pumped: "�"' C} oslkl m 3. Component: C] Cesspool(a) RwJ Septic Tank Cj Tight Tank © Grease Trap ❑ Other{doscribe): 4. Effluent Tee Filter present? C.1 Yes C&No N yes,was it cleaned? C] Yes 0 No 6. Observed condition of componant pumpedt @. System Pumped 8 G �a Name VaNds License Number Wind River Environmental T Location where contents were disposed: Haverhill.v)ilW P_ 40 S Porter St _ t3M&Oir . -J'f83a . . 61(lnabue ut Hauler ds Ma y� srpnaure a Reo4imo recipty jot attaaniadil y rwoiplt t90 �374-2382-_ tdfunn4>doo-14M 6yetom Pumping Recoaat Page 1 of 1