421 Pump Report 7-26-18 0.(P/0- 1711114=f.
-+ Commonwealth of Massachusetts
City/Town of • _ . ( .. . .
+� System .Puttt{�in8
EtAcord
C Form4 -
•
ow Ilea provided this tarsi for use by bed Bards of Heath.OtherUhtp f W be need,bol the
Information mut be substangaily the eagle is that prodded here.Before using`must ctbe dc ith your
m
local Boardof Heeith to determine the torn.they we.TheSyetem Punning dobe submitted.
the local Board of Health or other approving authority within 14 days1mm the pmnpin6
' accordance wth 310 CMR 16.361. 11 -.
A Facility informationt. -
aore 1. %ratam Location:
tatma an the .
S. •
moor-clan.
enas alp Code
a-m rpt
we me tomo � � Ct�r°n' � -.,�.
'a .. 2 Systan Gent. - - •l
t • 'V la bin rt qu tv'
' cG t-ent .
iti
uwa..tJ in�vt� Kg •
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sees.r0rass.►tom rar")
arrr«m
isk Oc • Tsps n.,a.?
• B. Pumping Record iNlti 2b-lg.:- -
7. 'Dated . Dab 2• Q!radb'Pooped: . edam .
3. TYPaofsyefem: Q Cetepaol(a) 0 Sepik Tank ❑ Tight Tank ,QreesaTrap
0 Other(describe): . . i .
. . 4 Effluent Tee Fftter present? ❑ Yee,flo M yea,'waa flamed? ❑ Yes
( ^�
8. System Pumped BY: . ' - -
..a . .
7. Location where canaria wen:deposed: 4- .
Ns 9.
SlpnmeorReceiving Fader - o.r - •
sclare�e-Remo•Page 1 off
ea meat