System Pumping Records (002) RECEIVED 07/28/2017 03:48PM 9787450343 Salem Health Dept
07/28/2017 15:40 9782814869 WINDRIVER PAGE 03/05
Z\ Commonwealth of Massachusetts
,p City/Town of
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 Location:
on the computer, Cr' /G r
/
use only the tab '/'G 4
key to move your Address
not
use the
ret S�—' MA C71q 70
use the return
key. City/Town State Zip Code
2. System Owner:
Name
mm
Address(it different from location)
City/rown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping /7
2. Quantity Pumped: Cj 00
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank 1 Grease Trap
❑ Other(describe); —
4. Effluent Tee Filter present? ❑ Yes 14 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C1'�rY
6. System Pumped By:
bS
tA`Yc SeN
Name Vehicle License Number
Wind River Environmental
Company,
7. Location where contents were disposed:
signature of Hauler Date
Sb
Signature of Receiving Facility(or attach fadlity receipt) Date —.,Nb
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