348 System Pumping Record 2016 Commonwealth of Massachusetts
City/Town of
System Fuming Record -
Form-4
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the
information must be substantially the same as that provided here.Before using Ns form,check with your
local Board of Health to determine 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 310 CMR 15.351.
A. Facility infomiation
sung. 1. System LOCHOOD:
cm ma
star,see
ha tab key Addams
tie yow•
f-do not
Guy! own
Stubs 7ip Code
2.
a Le System roctsi KIR
34 cstosANAG_F-icto Rv,
Mara=Of&Serest trom lamata)
onyfrown •
NG414 ROI Pn-N3
B. Pumping Record
Data of PoinPing Deb Quantity Pumped:
Telephone Number
3 Typia:Of aysbarn: 111 CeSSPODIE6 A!re eptierank 0 Tight Tank
Other(descdbe) Sm 1 125 .
)166d
0 Grease Trap
4. Effluent Tee Fitter present? d Yes If yes,was It cleaned?
5. Condition of System:
61013
5. System Pumped By:
• tintske . y.,,,de theme Number
sJt
• 7. LOCESIOrt whobe contents were disposed:
Storm4.clocs 03106
4.
.13 Yes7ro •
Signature of Fteoeiving Paoli*
Date
Date
System Pumping Sward•Page 1 crf 1