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70 Pump Report 6-7-18 • • />O/5 Commonwealths pf Massachusetts fi City/Town of Commonwealth .: 17,4:41,1a7 -:\ System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be 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 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 15351. A. Facility Information Important:When filling out fomes 1. System Location: on the computer, use only the tab key to move your Address - - -'- - - '- -- - - cursor-do not use the return key. City/Town - -- - - State Zip Code j©l 2. System Owner: yit2o �1� Name SCV02. Address(If different from location) - - -- -- - --- ,. City/Town State - Zip Code ".01214.� Cy — -- Telephone Number - B. Pumping Record „n 1. Date of Pumping �`L="`”7 �� -- 2. Quantity Pumped: ° "�� - - DateGallons 3. Component: ❑ Cesspool(s) ptic Tank ❑ Tank Tight (���-�� g ❑ Grease Trap ❑ Other(describe): H Cammz'I-mp -m or- 9-t/y 2,0cTom 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes No 5. Observed condition of component pumped: 7�7� C-c—wel —(�1k�faBS( mr— = a - .raj, TNSTY3-U% CiazfrtL�e5' Ply) DOC - ZEINS7mts- T-y oN TN Let 6. System Pumped By: 1/'fh r l S 1 to V o l Vehicle License Number ompany 7. Location where contents were disposed: V - -_ Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5farm4,tloc•11112 System Pumping Record-Page 1 of 1