176 Pump Report 10-5-17 Pr
1C , Commonwealth of Massachusetts
k, , City/Town of " -
System Pumping ecord
Form 4
-
DEP has provided this form for use by tical Boards of Health.Other forms may be used,but the
Information must be substantially the sable as that provided here. Before using this tom, 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 910 CMR 15.351.
A. Facility Information
when dna out 1. System Location:
hems on the.
computer,we
only the tab l®Y Address • . .
to mow your
usmr=do not y/rown Slate
inside down ciZip Code
2. �stem Owner. - ,
y0 U pt— 9Fa+'Q&g
cmNWTm I76 CO(.6 rot RV,
Address dr daremM from ballon)
aty/iawn . Slay tip Code .
12.9 rireffR TdbNbrn MmMr - - _B. Pumping Record -
. 4. Date.of Pumping CST 5f 7 2. Quantity Pumped: on G
3, Type:of system: FECesspool(s) }3-teptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Omer(describe): . .
4 Effluent Tee Filter present? ❑ Yes,Li1 No If yes,was it cleaned? .❑ YesNo
_ - 5. Condition.of System: % -� -
0. SYstemaWmped BY
V
Vst1I wok, . Veli
de License manner
7. Location where contends were disposed: w
Slapsor Hewer _ Dela
Shamus of Receiving Faddy Day
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