28 System Pumping Record 2016 Commonwealth of Ma chusetis
Citylrown of - jj��� 71firrril
System .Punrpillg'Record.-.
Form 4.
➢EP has provided this forth for use by local Boards of Herat Other Tonne may.be used,but the
Ldamatcn must be any the lane as that provided tab.Before 1*9 thistle,dtedrwth you
lard Beef Heath to deSS$theimt.tiey use.The.Sy.4tem Ramping Recordmutt be eubrnleed m
the tat BoeN of Health or other approving authority widen 14 days tom the pumping dale in - .
amcmorrce with 91 O CMR 16.991.
A. Facility Information
'gout 1. Syetent Location:
eaet a�rean .
am .Z NUin(�K12.6N �`CG1/4 ri "
A Name f nos t FuG(h&G
Mak Tip Cods •
carte
Beaver✓
t3: Pumping Record
S } r 2,`[&- 4 C 4
. -1. tad P mPIFI nuBralb Rnpect
3 . . /y/7
arms
a, Type:oFeyeferrr: NEI Ceespaololi Septic Tank ❑ iiflTardc ❑ erameTrap
El Otter describer
4. Effluent Tee Fitter preset? ❑ Yes
O. Cohdldotiof Systern:
Pod By:'
St.dio:MVO
atiratae orRee.M Far*
ayeiam Ptanpbe Reapi Pegs 1 er1