System Pumping Record 7-25-17 RECEIVED 07/28/2017 03:48PM 9787450343 Salem Health Dept
07/28/2017 15:40 9782814869 WINDRIVER PAGE 05/05
�Z\ Commonwealth of Massachusetts
City/Town of .C,1em
System Pumping Record
Form 4
DEP has provided this farm 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
Tilling out fors 1, System Location:
on the computer, i �.r 6\e\Y�
use only the tab `
key to move your Address MA
O``/�t�
cursor-do not
use the return City7fown State Zip Code
key,
2. System Owner:
Name
mn
Address(if different from location)
CityRown () to
Telephone Number CJs
B. Pumping Record
1., Date of Pumping ?ol 2. Quantity Pumped:Date I 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 condition of mponent pumped:
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were disposed:
Signature of Hauler Date ,
D.
YY�, Alf
Signature of Receiving Facility(or attach facility receipt) Date
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