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421 Pump Report 6-20-18 Commonwealth of Massachusetts LST '7-7 gL • r o80 • . c • - ' z ' - t . 11 . • , s -. A“i i1/ 4, G ! ' �'- '9 System Pumping Record ociemt, <7-21i DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the beet 00aR tiatiEalt$*thin 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:when filling out rams 1. System Location: on the computer, • use only the tab key to move your Address cursor-do not use dna return City/Town State Zip Code key. ©I 2. System Owner: — X A int-191'04 c�NTE-f Name M AIIN Address(if different from location) t�c�a 1 �-Cnry./rows s / / Zip C ode 1 }, V os Telephone Number B. Pumping Record 1. Date of Pumping p `0 2. Quantity Pumped:te Gallons 3. Component: 0 Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes o 5. Observed condition of component pumped: 14"00/ • • 6. System Pumped By: 1NRe N me Vehicle License Number S,(t 1v4 7. Location w ation? here contents were disposed: • Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5fonn4.dac•11/12 System Pumping Record•Page 1 of 1