320 Pumping Report 2017 6 1/°
Commonwealth of Massachusetts
Cit /Town of 00 / 4 7)4/10
System Pumping Record
rf :7 Form 4
DEP has provided this form for use by vocal Beards of Health. Other forTis may be used, out the
irfor m,at'on must oe substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record crust be submitted to
the iocai Board of Hearth cr other approving authority within 14 days from the pumping date in
accordance with 310 OMR 15.351
A. Facility Information
Important:
Wien rillirg o. 1 Sys:em Location:
,se
;;r:!,the tao key Address —`
yCv
cu:ser-do not
use the return Ci:yfrown State Zio Code
Key.
2. stem Owner:
SCiLZ
"nj2,0 U -\c 642.1113 2.1 3 '24/,
Address(if different from loca:ior)
City/Towr Stat �)'y,
de
(�n, � 77J.
•
FLokeN C� Tel :,81 ^Dumber
B. Pumping Record �?0,1�'� /1
Date of Pumping1e 2 Quantity Pumped: v
Gallons
3 Type of system: E Cesspcol(s) Septic Tank Tight TanK Grease Trap
Other (describe;:I�-CC17d1� fi t\7= rl r a�14Q— ! '&TIM .-
Csi ell, j"Toe--Pit sa rTro n,
4. Effluert Tee Fiiter present? _ Yes)2----No if yes, was it cleaned? Yes "—No
Condtion5. " of System,:—ficss Q rJ
,- vq,
_9 cf-thiP
6. System P roped By:
u v
Npe (7:5 sv_ //"�
evioo.,>//,'Jenice_icerse Number
c mpany 15
7. Location where contents were disposed:
CCC...JJJ +vC .
Signature of Hauler Date
Signature of Receiving Facility Date
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