22 System Pumping Record 2016 . al t /P-191, -:fi
t, Commonwealth of Massachusetts
' w _s City/Town of ' 0_4.. . � AT .
System Pumping Record -
Form4
. . _ DEP has provided Cds form for use by local Boards of Health.Other foh$may be used,but the
substantially Information must be
local Board of Health todetermine 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 h 310 CMR 15.351. '
' 1.
A. Facility Information �- ay
bnportant '1. -System Location: •:d..
yowl tang out turns on the
year-do not citocrom State zm .
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B. Pumping Record
T
. .1. Dee of Pumping SDU M o -i z. Quantity Pumpea )50 0.Gowns
3, Type:ofeystem: In Cesspool(s) 52'Sepdc Tank ❑ Tight Tank ❑ Grease Trap
'.�. Other..(describe): - .
4. Effluent Tee Filter present? ❑ Yes o tf yes,was it deaned? .o Ye c
5. Condition of System: -
GOG Q . '
•
B. System Risirpad By. -
ri , Y01/�J( I /-/ i VeNde license Number
7. Location whare contents were disposed: F
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