145 System Pumping Record 2016 commpnweaith Mas pchusetts
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City/Town of - is i A" 41 `
System Pumping etord.
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DEP has provided this fern for use*local Boards of Health.Other time mey be used but the
Minden must be substantlally the same setae Provided here.Belem ring t ie.fann,check with your
local Boaad.d Health to determine the form they use.The.System Pumping Record must be eubintlted to
the local Board of Health or other approving authority within 14 days torn the pumping data In -
accordanca wth 310 CMR 15.351.
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A. Facility Information
mop our 1. -System Location:
the
ron use aadresa ,
tab ayo wey
eyour.
"-do ewt • Gig/ram
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Merram
B. Pumping Record
. A. - of Pumping � 16, 2. l!arBbP! nPed: lesions-U
3, Type:of system: Cesappolta) -Santo Tank
❑ Tight Tank ❑ Grease Trap
Li Other(describe):
. .
4. Effluent TTee Filter present? ❑ Yes,1. o If yes,was It decried? .I] Yes IQ Nd
5. M0/ System:
0
5'7SC.02
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VWtle Uvulae ternber _
amebae of Reeentig Rua
arena rbc O3106
&deem Pumping logrd•Paget art