591 Pump Report 4-5-18 IF o(r// -Paa ji
Commonwealtho Massachusetts
Ci /Town of tI__ ri
" System Pumpi g ecord
I'
Form 4
DEP has provided this form for use by local Boards of Health.Other fotms maybe used,but the
information must be substantially the same as that provided here.Before using this form,check with your
local Beard.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 15.351.
A. Facility Information
Important ". .
Wren Laing out 1. System Location:
tom on the
computer,use
only thetabkeY Address - .
to move your -
cursor-do not Cibrtown State Zlp Code
use the retro
2. System Owner.
legit
B R 1-'rr?(11 `.lame 5-9 I C61 i�1oF�ln% Pci
Its Addressor different from bretlon) /� ZJp
tysou-k R n(PRin "II(��/(e/pJFwne N ✓umbxv/•
B. Pumping Record
n^
• A. Date.of Pumping �A/�i(,� i� 2. Quantity P 6 Goons
�s
"" aaa a
, 3. Type of system: I] Cesspools) Septc Tank 0 re-) Tani( ❑ Grease Trap
❑ Other(describe): " a/r3 phoim e;uT OLD pi e`J
4. Effluent Tee Filter present? ❑ Yesp-Alzr If yes,was k cleaned? 0 Yes
5. Condition.of System: '-I. /,t}t�_kt,r
..rind-J (N(-I -fo -Pure o, Bo/`. ,
6. t -meed By:
Vehicle license Number
rCny
ire , .. Silt hielk
7. Location nwhere contents were disposed: w
UV Sly
Signature of Hauler. . Date
Signature of Receiving Facility Date •
1form4.doo 03/o6 System Pumping Record•Page 1 of 1