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589 Pump Report 6-28-18 Commonwealth of Massachusetts • rp ; 1%. , , • -out• - : - . , 16 • n . - : - , a _ < . . „ 4 - 11 System Pumping Record n/© h 41419.746.)- '4,-C-#. p?O yt '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 tI ebettlt. Neagh**In 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When ening out forms 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 Owner ny1u�n. n /1` Zip Code II 2. System-PI I-4144JS Q71 , frifi(k. b7)96'lipcl u d20, Address(if different from location) City/Town or 71 afQ“r"r 41 m Telephone Number /�✓!, mber B. Pumping Record 1. Date of Pumping Two- ° �lg- 1560 Date 2. Quantity Pumped: Gallons • 3. Component: 0 Cesspool(s)l(feptic Tank 0 Tight Tank ❑ Grease Trap nn r,rN' 0 Other(describe): /--Q oar inno I CUD Ty p p 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes o 5. Observed condition of component pumped: • 6. „SSylestyenm) ngPyumped By: N ma n 1vk Vehicle license Number 7. Location where contents were disposed: uV d Q� Signature of Hauler Date Signature of Receiving Facility(or attach facilityreceipt) Dale - t5forn4.doc•11/12 System Pumping Record•Page 1 of 1