SYSTEM PUMPING RECORD 10-17-17 RECEIVED 11/22/2017 11:56AM 9787450343 Salem Health Dept
2017-11-22 08:04 TRCT-Newtown 2034260067 >> 9787450343 P 4/10
Commonwealth of Massachusetts
m City/Town of .,
�. System Pumping Record
Form 4
DEP ha$provided this form for use by local Boards of Health.Other forms may be used, but the
Information must be aubstantisliy the same a$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 16,351,
Important:when
filing out forms 1. System Locatfon:
on 1110 C Puter, — // /
use orliy the tap � C4'+"Cx .',G^i
key fr move your Address
use,0*return .f. MA
key, City170twt .. $fete
Zip dodr
f j 2. System(Neater: /
Nam i> /
state
Trlepnarng Number .
B. Pumping RecoW--_..._- ____.__ -
1. Date of Pumping /0 ,/?, /7..- 2, Quantity Pumped:tMtr ....__..__,. ...-. ._.,. .._...._,
Qaibnw
3. Component: aCaaspoot(s) 0 Septic Tank [] Tight Tank Fj Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? 0 Yss A No If yes,war i1 cleened? L] Yes [ No
6. Observed condition of component pumped;
B. System Pu By,
. VrMdr Eicrrlcr NumErer
Wind River Environmental
7. Locaflon where Col were disposed:
Biprigturr of R•odivinp FrdUty ter attach faclisy reae�q Data'., .....•—.... ............ _ ,... .._
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