421 (VA Hospital) System Puming Record 2016 o(V/p-1711J1i
+ Commonwealth of Ma husetts
f/ City/Town of r [ 1 /y
M System .Furrprig
.
Form 4-
DEPies provided tl>sidrofor use bjIocalBoardsofHealth.Ober tame may.be used,but the
-Udormatiot must be substimtbily the eapte ea tat provided here.Before using thlefam,d,edc with you
local Boarded 1,1e2dth to determine Melon they Use.TheByatern Rasping Ramat must be su
oc iBoar dalHShtodertdroth elontheyrse.TheSystemPaspingRamdmust besv to
the low Board of Health or other approving authority widen 14 days tern the pumping Me in -
accordance with 816 CAR 15.95E
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A. Facility Infonrietlon
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- B. Pumping Record -
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1. oar of?rnwng r :k . ¢u�rb rex .
8. Type OFgyefon: ' Q Caeupcc4(s) ❑"Septic Tank ❑ Tight Tanic efir GNAW Trap
4.. Emuant Tee Hear insert? ❑ Veep(No- tfyes,wea adamied? D Y -
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. 5. 6ondleorcof System: t .
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7: latardcn whets were dis owed: F
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