291 Pump Report 5-8-18 + ` ComrTtanwealth of Masspchus
r City/Town of � I � �
System .Pumpl Recoo
Foran 4
. . _ DEP hesprovided this fomi for Use by local Boards of meal.Swum!now be used,but the
brthnnatlon must be geomerepoy the else totem prodded his.Before wing Notch,chock with Your
local Bosnia(Health to debami s thelbrm they use.The.tyetem Punping Record must be subedited to
the local Board of Heusi or other approving authortgl whMn 14 days tom the pumping data in _
accatdance wbh 310 CMR 15.951.
f;
A. Facility Infortngt Ion
,
won do buportme 1. Bystem i.aaaman: 'd,
Bane an is
akin lay a ,
eraaw yen '
wear;do not door mCoda .
wets item ' - .
ay. • i Sy rn fir14W-14 ' - -
. •
-
Moms 2.9 ( 1--1) ew V tka.e. go, .
/yid's'.Mint"tom Ina040- -- L app
LVAD tta • �f(3 3) 0 -di-) �ar`
B. pumping Rsco .
Sim` to0 •
. 4. `Date d Panptrg . oras _� quenitb'Pomped: . Gees
9,_ Type of system: IF3 SesnseI(a) p iepd.Ts ❑ 713W TsNc 0 Grease Trap
. . ❑ Outer(deegthe): 150 To �'ciW Qoltzn �/
• 4.. Murat Tee Fester present? ❑ Yen ,$ Ho lfyea;was tdear"d7 .❑ Yes Lf Ne
n.
5. . Cotillion of System: •!
1,{)`'(,e-E.- LCI: tt89-134LyMl'1)`+ etPLI IN Lei' 7-- ( - tNS/7i(.L.
wt-s€1, DIU
OUTIL i, •
, . t 6')9SOr C.;4 r3 ill Si ,
6V�C
IS ` Si L tiro
7. Loraitlon where corttentewan mSCOeed: 4 -
SlpllalR oftrelr. .. . • Osta
Signature o&RnMig Peaty Dela
aprM.aocr enact aytu PSrpha RemN•Pica 1 of t