600 Pump Report 5-9-18 a;(Gi/P-40.7, -.:Cd
AL Commonwealth of Massachus
07, City/Town of 701
r • System Pumpll�' Re
j Forth 4
- DEP has groveled this tori for use by local Boards of Heath.Otherldmemay beused But the
kdametoe must be subat r*ty the Earle m thd Provided here.Before usir g thNdohm,check with your
local Boadof Health to determine thalami they use.ThsSydsn Pumping Record mud be submitted to
- the local Board of Health or other approving authority within 14 days from the pumping data in -
accordance wtlh 910 CMR 15.981.
A. Facility Information
r
t. Syetarn Lacallon: - ..I,
cams on the
aompuler,use
only IS tab lay After • .
trrmoy*sera - -
anm-dg notdeer
- sate $Lase • -
uemereaerr _
..,
.oct 2_ Owner:
Co&3WtLL . k5.5e (
ko NhyP�� IC<<
MaM'Reesatumboa e
- �oS • T`v? 7s, ° " -
TaYipere ramtl.r
B: Pumping Record
Pa
1. Date.of Pumping bide 1 ilj• c42. QwrrayR.alie& . Gala
- 9, Type.of-sysfem: 13 composts) )2'tepasrenk 0 Tight Twit 0 furore Trap
D Other(dasalte):
4. FAluent Tea Filter present? 0 Yee No Ifyes,"wse It Gleaned? 0 YoSI
(`-D on
6, Wal By _ _
I��'°ripic
, � et/ds lleLimnertimberri6timber ,�
Stmt tiWo( ,, V
7. Lcesdfon9whers cornerde were deposed: ,.
SlpNeeea boles _ Deis
Signature ofResN.w Fatly
momwaeawoe . Byre Perces Flaccid•Page h ah
._