30 Pump Report 5-29-18 ' Commonwealth of Ma setts
City/Town of - r s*k*+`
" 1 System "Pvefpiirg'Record -
J Foam 4, .
. . _ DEP hes provided this fain for use billets!Boards of Health.Ober forms may 6a used but the
Information mud be substantially ths sign a that provided here.Before using Was:fame chock with you
local Boardof Heat to determine theform tiny use TheSyetem Ringing Record must be euMnhmd to
the local Boer!of Sam or other appmWg euthonly w6tdn 14 days from the pumping date In , '.
accordance with 310 CMR 15.351.
A. Facility Information Fs
p
_. vornaa 1. -Syatern iocatlon: .
fans oethe
• use
m• nrw yar.
oar:.do not cag.
Sala - 4 Coda .
unto nem
cich acorn 3c) P,;c;j j-loa W 7L-61, .
asaewrteaerat tam memo!+
t6le Nei 7S
B. Pumping Record •
` ' . -1. q te.of Pton ing : Y / , ail ;2- Q!sn64r . . S
. . 3. Type:oFeystem: ' iin CCeeepad(e) Tat 0 Tight Tank 0 QreeaeTap
❑ other(describe): N Co)9c9 Pi eN r
• 4. Eleuert Tee Filter present? ❑ Yee,�1 Ifyes,'waa It cleaned? 0 Yee - No
5. Gondson.d System: �. _r -
8. rinal
5 / Vele*LIMOSrumer .at C5
• ?: Location where l Were deposed:
6vS �
arrau.eartls.r� ... r>er
eq.aas of Readying Rao - am
1apTdlAomMoo - Ern PUOiea-Rd•POO 1 oft