26 Pump Report 9-27-17 a.(f//D- CDU'
14 Commonwealth of Massachusetts
• 4 ,t City/Town of AI 21-
-,117A 4 .
w
System Punipidg ctecord
1. Forth 4
•
DEP has provided this form for use by local Boards of Hearth.Other forms may be used,but the
Information must be substantially the same as that provided here.Before being thlafort,rthedc with your
local Board.of Health to determine the form they use.The Syatern Pooping Rent must be submeted to
the local Board of Health or other approving authority within hin 14 days from the pumping
accordance with 310 CMR 15.351. ,
2i
A. Facility Information a9
witntreVIZ.tat out 1. System Location:
fame an the
aompubr,use
orty eetIbseY Addreee • '
03 RIO.Your '�`
State
arson-do not
usown e � .'
�` 2. System Owner. -
)nt4cC-- Ce-kir- t
0;19-G CENT It ST(dNaee'(e debar*from nom)
k-)071�-1 rci - :ream.
B. Pumping Record •• a
n.2. Quantity Pumped:
" . -1. meat pumping Date
3. TyPedF system: 13 Cesspool(s) ❑ Septic Tank 0 TIghtTart 0 Grease Tree
Sew( =tvattCra? Qum :
- ❑ Other(describe): s
4. Effluent Tee niter present? ❑ Yes , No tryes,wee!Weaned? .❑ Yes
_ - 5. Condition of System: i
61
8. et\Bf(t�t'Pumped By:
V V u\� yeNtle Clones Number _ '
L'5 `Ssko woo€
7. Location where contents were deposed:
NSQ --
.. Sipnehee ofFbYar. bee -
Straka of Receiving Fatly __ •
ElMellen]Record••Pyle t or 1
abmM.aav ass* -