SYSTEM PUMPING RECORD 6-29-17 RECEIVED 07/28/2017 03:48PM 9787450343 Salem Health Dept
07/28/2017 15:40 9782814869 WINDRIVER PAGE 02/05
Commonweao-Massachusetts
City/Town oflV��
System Pumping Record
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 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 15.351,
A. Facility Information
Important:when
filling out forms 1. System Locati n: I
•/- (
on the computer, ����-����CCCC �U4 c ^
use only the tab V_ V ' K�W
key to move your Add
cursor-do not MA
use the return
key. City/Town State Zip Code
yf� 2. Sy^M Owner.
LVSL%ce ) O� [A/\O��rl
Name
Address(I different from location)
CilylTovm State Z ip 6ede Z`
Telephone Number
B. Pumping Record
1. Date of PumpingDate1 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) &Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed conditil f component pumped:
6. SysFRiver
ed y:
NamVehicle License Number
Winvironment
company
7. Location where contents were disposed: 7
Signature
outer Dete
S.E.S.D.
O
Signatum of Receiving Facility(or attach facility receipt) Date aye.,, M
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