184 System Pumping Record 2016 ortant
on Sling out 1. System Location:
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npuer,use Acidness
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sar-do net City/Tenon
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Commonwealth of Massachusetts
City/Town of (y or4-h4-m?pfp7'
System Pumping Record.-
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DEP has provided this form for use by local Boards of Health.Other forms maybe used,but the
information must be substantially the same as that provided here.Before using this form,checkwlth your
local Board of Health to determine the form they use.The System Pimping 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 Information
2. System Owner.
np Code
AdSose'(If 6aermn from laanon)
caytrovn Stag-14' I-3°Cc'"°
-rn�� �V VUMt rY's iU I"V") Telephone Number:
El. Pumping Record
-1. Date of Pumping ( C�t tV i b -: 2. Quantity Pumped C a
0
Date Gallons
3. Type of system: 9 Cesspools) - I Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other.(describe): T
4. Effluent Tee Filter present'? ❑ No If yes,was it deered2Yas ❑.No
5. Condition.of System: -
R. SV+lnP mped By
aids St1�. GJD�k,
7. Location ere mntente were disposed:
ymk.doc 03!06
Vehicle Ucense Number
Signature at Helder. ,
Signabrre of Receiving Red a?
System Pumping Record•Page 1 of