297 Pump Report 4-4-18 ate( rr' /U- peva
Commonwealthof Massecht,septts
I 9 r� City/Town of �
System .Fuer it :Recd
/. Foran 4
DFP has provided this IS far use by local Boards of HeeMh.Ober forms may be used,but the
Information must be eub6tandalty the ewe as that provided hero.Before using tds berm,check with yotr
local Board.of Health to determine the firm they use.TheSyatarn Pumping Record must be submitted to
the local Board of Health or other approving auuCwdty wI hin 14 days them the pumping detain - '
accordance with 910 CMR 15.951. or•
d Facility Information
t?
Wen out 1. -System l:ocemon: _ ., a:
ram.on N.only Ihe tab key Mime • ,.
. .
moor-do not city rows 81261 apse •
weft ream
%W. . . •
_
Hare. c� 77 )4MVI N) Vl 11,e Vtp;
B. Purn#fing Record .
p
t. 'DateofPunt .f ' 1560
4z nuanaty t�tenped: . oron,
. 3, Tipa:ot el's4am: . IC Cesspool(e) pp��S Tank El light Tonic 1:1Gres:307w
El Other(describe): I- CG rra) r w(NO -PArtC4
4. Eatuert Tee Filter smart? ❑ Yes ,y No Ifyes,'was It cleaned? ❑ Yes t:1rno
8. SysZnePumped By" -
ray C `.Sri G IV Di ,.;i i.-c• . vatisu neWmMr
7. Loc9tlon where contents ware disposed: �,
8haa or RaoeMV Fad •
WorrTNAor Mae System Pumping Rsapm•Paas t of 1