21 System Pumping Record 2016 Sti, Commonwealth of Massachusetts
re k _ � City/Town of - lU . ' ,1),,t�
M System Pumping Record -
Form 4 -
DEP has provided this form for use by local Boards of Health.Other fotms may be used,but the
information must be substantially the same as that provided here.Before using Natant ohedcwith your
local Board of Health to determine the form they use System Record be to
the local Board of Health or other approving S s fie g er e in
' accordance with 310 CMR 15.951. ,
A. Facility Information ,,
re out 1. -System Location: - ..
forme on the - .
*totabkey Address . .
m ser
weor return city fgarn Sae ap Cade .
Imams nrhan
kW' 2. Svatem Owner. t
n` �S jt\m 3 Qc .
aameee Ofaamerp I / J,,
Coy/rows •
- 0Q t, eC; - ?
B. Pumping Record
A. Date or Pumping •N . )31 (e' . z. o Pumped: 9`u O 6
s, Type:ofsystem: In Cesapoot(a) Septc Tank ❑ TlglrtTank ❑ Grease Trap
0. Other(describe): - +
4.. Effluent Tee Flier present? ❑ Yes No If yes was It cleaned? 0 Yes o
5. Condition of System:
{To1
- B. System mped By: -
(Y P
ri ti: r t G.✓_ O(/ yeWde umrea Nutter
7. Location where contents Were disposed: o-
Smre:WM ofRem M g Featly
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