167 System Pumping Record 2016 •
Commonwealth of Maasachuss
, si City/Town of " 10_ i 64 "+°
_ r System Pumping Record -
Fonn 4 -
. .a, DEP has provided this form for use by local Boards of Health.Ot err hh may bee farm but the with your
information must be substantially the seine as that provided
local Board.of Health to determine the form they use.The System Pumping Record must be submitted tc
the local Board of Health or otter approving authority within 14 days from the pumping date in -
accordance wt h 310 GMR 15.351. ,
A. Facility Information
4
wean Inv mg 1. System Location: .
tams on to
computer,use
only the .re tab key Address ' •
to moue PM State - •
cursor-do not - gty/rawn
use the reoan -
2. System Owner. - -
in P Cs-0Ll c 7 n G
cjitn nm e /67 h 1=y4Q nS RP
Address-CS dement tom brim g
caprrwm • 8,773• L/94S:; 64/ -
--x121— C. TeepwasN,meai
B. Pumping Record, QOQ
(r. E/G
. A. Date of Pumping 1 oma ..,2. Quantity Pumped: eakes
3. Type of system: I l Cesspool(s) 2 sepac Tank ❑ Tight Tank ❑ Grease Trap
- ❑ Other(describe): -
4. Effluent Tee Filter present? 0 YesfX..�ge If yes;was R cleaned? 0 Yr.-alto
5. Condition of System:
Gn
5. SSYsterr�r�()1 sped BY - .-
`! _ Natick License Number -_ .
regyny 1 Silt Pi/D(4110-1
7: Location where contents were disposed: r - -
S Qi.
Signature of HSier. ... Date -
algreli a of Ramming Fedi* System Punpeg pact•Page of I
taomM.am•Delve