112 Chesterfield Road Pump Report,r
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Commonwealth of Ma aSt§pi
City/Town of ' . .
System .Pteeping'Record.-
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DEP has provided this form for use by local Boards of Health_Other bh$may be used,but the
information must be substa tionn the same as tat provided here.Before using tds form,check with your
local Board of Health to Mamba the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority with n 14 days from the pumping date In - •
accordance web 810 CMR 15.951. - -
A. Facility Information
1. System Locator:
2p Code •
aae7aasteam rocatinu
Clefravm
B. Pumping Record •
A. Date of.pumpfr� o L*91. �� Z. Quemoy PUCaPed:
GAMS
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3. Type:a syefem: E1 Ceespo*sj - SepdcTenk 0 lightTanlc 0 Grease Trap
0 Other(descibe): . . .
4. Effluent The Filter present? ❑ Yes,rp No ryes,was It leaned? ❑ Yee,jaerNO
. 5. . Condton.of System: -r -
Cr OD !-,F %t° 6k 66:9Lrlce:SPTh
6, pad By:"
t Sl4 wit -e
7. Loraiton
mrtAOV 0406
mrden7s were deposed:
Yodels Llama°hater
stomps odes, ...
metre ar PaceiMg Fad
sydera Pumpyp rmmN Pena t oil