367 Pump Report 4-26-18 c;IP/P-PDW-1;
-+ ` Commonwealth of Massaehus, i.s
' , City/Town of N p.7 -+4.ord
0,. f
+� system .Pumping itec
i Form 4. -
DEP has Provided Oils famfor oath/local Boards ofMeal&Oliva Urns may haused,but the
hdotmetlon mud be substantially Its Hume eats!probed here.Betas using tit tam,cMdcwnh your
local Board.of Health to determine the form they use.The System Pupping Record must be sttrrdlmd to
the loot Bogard of Health or other approving authority vAlhin 14 days from the pumping date In ..
accordance with 370 CMR 16.361. •
A. Facility Infortriatlon la 9
vitotnetrjnaom 1. -System Location:
soma on tie'
can
onlytiw roti Mean • _ . .
bnhar ties. -
alibi
onot *✓rte _
State
.
ustlrheam - -
.
.i
•
W Pre O 1 t: )5(44-2,0n3 Uva/. .
Meer'lasesmtamo balsa
aerrroym - • a. /3-5-/ t " 7r", 11,
GN CC? T"eahw-"see?
13. Pumping Record • - •
` • 1. Qate,of•PumPlrlg • 1� '
Quenety Pumped: . odour
' , 3.. Type:ofsystem • IE Cesspool(s) 9aptic Tank 0 light-lank 0 Grew Trap
• - " ❑ Other.(describe): .
. . - 4. Effluent Tea Filter Masan? ❑ Yes No t yes;wes It deemed? 0 YNO .
- 6. �Condtlon.of 9yetem: y / .
G��ra��Ct�pfOPx -1 i
t• V�'.; 'hU J Ped BY: •` - _
Irpt' Vdaob llmaeeahlar
,s %stk wet '
7. LLond ahviestConnate Were dbposed: t '
0 U ofHH.ar.
eon:m.0 QFad' OW -
heamMAaa cave8yaem Pumping Reaped'Peat ori