19 Title 5 Pumping Record, 2016 When filling out
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ady the tab key
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Commonwealth of Massachusetts '
City/Town of
System Ptmrping'Record.
Pone 4
DEP has provided this form for use by local Boards of Heath.atter farms may be used but the Information must be substantially the seine as that provided here.Before tang thls.fam,check with your '
local Board of Health to detem ine the ionn.they use.The System Pumping Record must be submitted to
the local Board of Health or after approving authority within 14 days from the pumping date in -
accordance with 310 CMR 15.351.
4•:
A. Facility information
1. System Location:
Mess% •
dy/Tarn
- 2, System Owner.
F R&sTota
Zip Code
N 4c\ Coconut week
Sadism-0i @Smartt torn locIbn)
CItyllesin
MO;NCEI
B. Pumping
. Record R (, 43• 1G
4. DateofPumting Data •
3. Type.or system: E Cesspool(a)
❑ Other.(describe):
4. Effluent Tee Fitter present? [] 1/es No yes,was It clasped? .O Yes
2. Q,
T= k
3-
Pumped: oemrn
D Tight Tank ❑ Crease Trap
ZS
5. Condition.of System:
( ucC .
8. System
4 V Pad SN �/
t. Stir &o%�;:, . yetddaIJOgse Nutter
7 LLoc tion ire contents were disposed:
pigmies of Receiving Fadgy
hem 4.deo-owe
System Rasping Pasant•Page 1 0,