39 System Pumping Record 2016 I
07P/P- Pod
C, Commonwealth of Massachusetts
I,
i- ' sd .fi City/Town of 0 4 (-6,2
i
- ri ,:, System Pumping Record
- Forma .
..‘,.
DEP has provided this fan for use by local Boards of Health.Other forms may be used,but the
Information must be substantially the sane as that provided hem.Before using this form,check with yc
local Board of Health to determine the form they use.The System Pumping Record must be submitted
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
Irnporflt
whensung out 1. System Location:
toms on the
consular,use
anti the tab key Address
to MOW your
cursor-do not atorown State Bp Code
me tbe return
2. System Owner:
Ifill , —
ime --Prg 01\‘? • rirl
cilt '69 Ci OVA Wk
mantis(if different from imam)
• Cllyfrown . 73, vy'L Vcr
F,4JOZ:t.'>1%QQ--
5. Pumping Record
4. Date of Pumping Date .. 2. Quantity Pumped:
• 3. TYpe itif system: 0 Cesspool(s) „EfceptoTank 0 'light Tarn 0 Grease Trs
• 0 Other(describe):
zi.z/
4. Effluent Teo Filter present'? d Yes No If yes,was It cleaned? 0 Ye212-"C
5. Condito System:
• B. Mead By.
I
r
Pt ;a_ - I t W Ork ' Vette Lkense Number
7. Location contents were disposed:
• Signers atRauler ,
• SignEdunt of Receiving Fade/ Dats .
drorm4.dom Dartre System P•nsem Record•P