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System Pumping Record 10-20-17
RECEIVED 11/22/2017 11:56AM 9787450343 Salem Health Dept 2017-11-22 08:06 TRCT-Newtown 2034260067 >> 9787450343 P 7/10 w eorYimomwe+ ok "Is iw►r.`+atMa,«a.«.ar 1 Cityfrown of t.1vo System Pumping Record Forms 4 DEP has provided this form for use by local Boards of Hastth. Other forms may be used, but the information must be substantially the some as that provided here, Before using this fort,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 data In accordance with 310 CIVIR 16 361. A. Facility Information Unporuft viiH When 1. System Location: on the compuatr, Ursa any tha tab .- ._.�.Fl..._.,..,....LC+� ep�--._ .!_.._..._....._....._.____ - ,_._.._..._..____,_. __..._ key to moue your AddrmaCursor-do WX 5/,,,, q r� Uw the ntaum -.—_..�_w� __.____ 6t e_._.._.._.,...._. ... _!7a` ._.,.... key A"WC1 2. System Owner, ,a Narita AOdreea(trdtftrent from fowann) 011yrtowrt._._.�,_. ..__..._.w..._...�....._. 9tete......_.,._..._._..._.._.,... lpCoda_,..._...._.._.,__._. Teletihana Ntanber B. Pumping Record 1. Date of Pumping oao ( 2, Quantity Pumped; CARO" 3. Component; 1pi Cesspool(s) M Septic Tank © Tight Tank [ Grease Trap i3 tither(describe): 4. Effluent Tito Fittar present? (] Yes No If yes,was it cleaned? (_'1 Yes ❑ No 5. Observed condition of component pumped: 6, System ware Pumped By: Vahtcte Leona Nwn ar Wind River Environmental 7, Location where contents were dispoaad; $ipnaWm of HaUWr -».-.._....,..�..,«.,,..-.......--._—._..V4 9ata ......_.._...�...........�,.....__........,...._.......... 'S(gnatum+srRecawtlRradttrytWatlac4tfoolly(44*0) p, —.._.__._,..__.,.._..__.__ -......,......,.�....-,...-._.„..__.- t6formllooa-11112 systnn purcraing RaconE-rasa t nr f