124 Pump Report 5-9-18 •
Commonwealth of M chusetts .
' , .•; City/Town of - p fo'. .
;" System .PuirO*ecord.-. _ .
Form-4 .
• DEP in provided this tan for use by locat Boards of Health.alba time maybe treed,but the
Intonation mut be aubatanSitY the settee as that provided here.Blore using thtetnn,chedc with you
local Boad.of Heatth to determine the form they we.The.byatam Pumping Record must be submitted b
. the bad Board of Health or otter approving authority?Albin 14 days from the pumping date in - .
accordance with 910 OMR 18.951.
A. Facility Infotniatlon
. itsjout 1. -Bystem Locator: • `.
ami.a,me. +}
IS actry�, kW"'
mnaeyea.
anorkla not . ant
tea n - Stab e
tombs Tom -
SO ." .Oft sm. hh� ..
I/9-4 egG'Srea2P(e E D (<o, .
edaw,eorninnaem IO l) _
r>aeraen - • P3- i-// - - -
-i'l)Thos Traps. . `
B: pumping Record .
YD� 1 `� 1� Cr0 .
. A. Dets.ofPanpba rd. .,;Z C)veneb Pumped: . 'a✓raa
3,. Type oftystem: • IC Casepool(e) •jkoaptcTenk D Tight Tar* 0 areaee.Trap
•
- - ❑ other.(describe): . .
4.. abort Tee Filter present? D vesykg tyea.wee It Salted? .0 ver •
nn
Gan,d`RRtandSyatem: /'s .
IToC)4S-t) . A
.
8. a ped Byt . ' .
•
yad.tb...rum.r .
. . ,Lc `Sot. G✓D
7. Loxton ereconmaila was h9epoesd: 4.
Qvsy —
�.•� ore
Sbrates orneeang Feely P
s/anr4.dar oaee - - system a seem'1•PN'at
. •