System Pumping Records 2013-2017 (need to be separated by address) (004) RECEIVED 07/28/2017 03:48PM 9787450343 Salem Health Dept
07/28/2017 15:40 9782814869 WINDRIVER PAGE 04/05
�LN Commonwealth of Massachusetts
Cityrrown of SoAeyy,
System Pumping Record
,p 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 cornputer, 2 �1
use only the tab \ \I
key to move your Address_
cursor-do not C�'�Yvs MA
use the return Citylrown State Zip Code
key.
0-71
m
2. System Owner:
Lo,e-\\
Name
Address(K different from location)
City/rown State Zip Code
()
Telephone Number
B. Pumping Record
1. Date of Pumping UDate I aa� 2. Quantity Pumped: Gane
3. Component ❑ Cesspool(s) 1?9 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes A No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
U�
6. System
Pumped By: %
1(n C
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed: Haverhill 1A wTp
Bradford_ �a 0183fi
Signature of Hauler
'M78) 374-
2382
Signature of Receiving Facility(or attach facility receipt) Date
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