326 System Pumping Record 2016 0(!//0-40W-3i
Commonwealth of f�,assach/u exits
City/Town of N Of ip—f
System Pumping Record
Form
DEP has provided this form for use by local Boards of Health.Other forms m y be used,but the
Information must be substantially the same as that provided here.Before using thisfoin,alt with your
local Board.of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Heat or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351.
A. Facility Information
lmportmrt
Vdren filling out t System Location:
ferns on to
mitigator,use
only the tab key Address
to move your
oisor-do not - City/Town
use the roWn -
2. stem owner.
R
32,(0 Q MC�s1 6Z F1tC—c0 RQJ
Mtlrese'(a deferent from location)
derrown
1-k" QS
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T - Number
B. Pumping Record /�
. 4. Date.of Pumping /(V- ...___2. Quantity Pumped: ) 66d
3, Type of system: - 0 Cesspool(s) L epac Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter preserd7 ❑ Ves L1'Plo If yes,was It cleaned? 0 Ves La'r'go
Condition 5. Conon of System: ./
(�-COIF
5. S \mp 0.ed By:
J`) �<AOi{ Vehke License Number
7. Location contents were deposed:
s
Signature of Hauler.
wom,4.do •03/06
Signature of Receiving Fad0pj Debi
System Pumpta Rec?rd'Page t of I