Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
1 PETER ROAD (2)
t a m E:A KEEPING YOU ORGANIZED No. 10330 153L MK RECMM YY wmm CONTENT10%�; cptll'.a Fa.wrc.Ma GD".TrMI^10,1(8 r.m�n MADE RI USA GET ORGAN IZED AT SMEAD.COM RECEIVED 10/06/2017 01:39PM 9787450343 Salem Health Dept 2017-10-06 09:39 TROT-Newtown 2034260067 >> 9787450343 P 2/4 Commonwealth of Massachusetts C4 City/Town of System Pumping Record Form 4 DEP has provided this form for use by 10091 Boards of Health,tither forms may be used,but the Information must be substantially the same as thatrovided here. Before using g this form,chock withY Dur local Board at Health t0 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 316 CMR 15,361, A. Facility Information Important:When OPino out forma 1. B tem(/,'L')pcafi7n, kethe y tomoveuteut se` I..,. M only fire tab Yo . ............. I-, /i ,..A,..�...,. cursor-do not i •@_` .L .........._.. .MA 0 S )6 use the return key. ckocwn State 2 8 dem Owner, r Addroaa;M dkYar&nt hem facatldn) Ckytfdwn Stnf Zip Colo _ _ Telep"ne Number B. Pumping Record 1. Data of Pumping o.y lagl/.7 2, Ouantity Pumped: (_ �?� OGloomm na 3. Component: Q CesspoolM ["ueptic Tank 0 Tight Tank ( grease Trap C7 Other(daacriba), _ .m __,. ... . .. 4. Effluent Tee Filter present? DKes 0 No If yes,was it Cleaned? aa' © No .., 6 Observed condition of Component pumped; t ^__.._ ......_..__ �d `�..... . .. ........ . 8. tam Pumped Vehldie W0n$A Number Wind.River Environmental - company e(�t'�� C �n _. ... A?�EAD. 7. Location where Contents were disposed: e.. �awra ar color oanm aigneturo oY Recsiving Facil%y{or agadh W-16,M,rewlptli data. . ._....__.. ... ............ .... ..... tetenn4,dac•iit12 System p umpfng fiaaoM page t of t