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FORM 4 - SYSTEM PT -7,22';G RECOp � ,
Commonwealth of Massachusetts
. Massachusetts
System PumRine Record
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JUN 18 2009
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��._ of �.: � � _ Quantity Pumped: gallon:
Pumpe^ hX (Compaw): � t>>> I��ll� rl/ Per !i
^'.s tranSier?ed to:
Pumper Si5-naz re /
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r
Commor.wealtr. of ;Massachusetts
��assachusatts
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Yes
CITY OF SALEM
r BOARD OF HEALTH
0222017021
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
0572212007
Form 4 -- System Pumping Record
System Owner System Location
Hawthorne Cove Marina Hawthorne Cove Marina
10 White Street 10 White Street
Salem, MA, 01970 Salem, MA, 0197 L
(978)-740-9890 x (978)-7$0-9090 x
Ben t ,
Type: Emergenc
Cesspool: No
Date of Pumping: (�
System Pumped By: Wind River
Contents Transferred to
Contents Disposed at:
Routine A- ,--�—/
Yes Septic Tank: No X Yes
7 Quantity Pumped:S� 30 Gallons
vironmental, LLC Permit #:
Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved Form -12/07/95
� SSD ��a
0222017228
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
05/21/4607
Form ;--5yste ing Record
System Owner - System Location
Hawthorne Cove Marina Hawthorne Cove Marina
10 White Street 10 White Street
Salem, MA, 01970 Salem, MA, 01970
(978)-740-9890 x (978)-740-9890 x
Ben
Type: Em
Cesspool: No
Date of Pumping:
Routine
Yes
Septic Tank: No = Yes=
Quantity Pumped:11SEC Gallons
System Pumped By: Wind River Environmental, LLC Permit #:
Contents Transferred to:
_ r
Contents Disposed at:
Date: 1 -/ Pumper Signature:
Condition of System/Other Comments
Dep Approved Form - 12/07/95
RECEIVED
iAUG 2 2 2001
CITY OF SALEM
BOAR® OF HEALTH
Nwillr� �t�)
System Owner
Hawthorne Cove Marina
10 White Street
Salem, MA, 01970
(978)-740-9890 x
Type: Em
Cesspool: No
Date of Pumping: v
System Pumped By:
Contents Transferred to:
Contents Disposed at:
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
06/22/2001
Form 4 -- System Pumping Record
System Location
Hawthorne Cove Marina
1.0 White Street.
Salem, MA, 01970
(978)-740-9890 n
Hen
Routine �
Yes Septic Tank: p No � Yes
Quantity Pumped: l Sb Gallons
Wind River Environmental, LLC Permit #:
Date: � � i Pumper Signature:
Condition of System/Other Comments
Dep Approved Form - 12/07/95
5
RECEIVE®
IJUN 5 2007
CITY OF SALEM
BOARD OF HEALTH
Pu;;:: <'-1U
Commonwealth of Massachusetts SEP - 8 2006
City/Town of SALEM/rlC CITY OF SALEM
System Pumping Record BOARD BOARD OF HEALTH
y` 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.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key
sl"
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A. Facility Information
1
SALEM MA 01970
Cityfrown state Zip Code
2. System Owner.
HAWTHORNE COVE MARINA
Name
Address (if different from location)
CityrFown
B. Pumping Record
1. Date of Pumping
3. Type of system: Q
❑ Other (describe):
8/8/06
Date
Code
Telephone
1000
2. Quantity Pumped: canons
Cesspool(s) ❑ Septic Tank ❑ Tight Tank
4. Effluent Tee Fitter present? ❑ Yes 0t No
5. Condition of System:
6. System Pumped By:
Benjamin Shute
Name
J's Septic & Drain
company
7. Location where contents were disposed:
SALEM TREATMENT PLANT
t5form4.doc• 0501
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
vehicle License Number
8/8/06
Date
system Pumping Record • Page 1 of 1
✓�. PEARODY, X 471
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LK
Commonwealth of Massachusetts
Massachusetts ,nn 6 1997
CI i -V OF iIALEM
H _,4n l'DEPT.
System Pumping Record
Date of Pumping: r!A 74 / Quantity Pumped:1�2 gallons
Cesspool: No ❑ Yes Septic Tank: No ❑ Yes ❑
�p r
System Pumped by:...n ...:.. ..... License # ....:.
/t
Contents transferred to:`l. ,
Date
Ad 1 �. Inspector
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