569 Pump Report 4-11-18 o7'/U-Przw.J.
=+ ' Commonwealth of Massz usatts
• - r '' City/Town of i 4.h;,u ,
r). System Punrping brd G
1 Form'4
. . . DEP hes provided this form for use try tical Boards of neat Other Tahrr may.be used,but the
kdormallon must be attlwtangalty the spine sate provided here.Before using this hsm,shad(with your
rood Boerd.of Health to dehermlre the forth they use.The.System Pu npkg Root must be euhrrllmd to
the load Board of Health or other approving authority witdn 14 days horn the pumping Ms In -
accordance with 310 CMR 15.361.
A. Facility Infonnatlon • #s
o.- 1. system t.ocedoer: .. ' :
stators• • .
only lha by Atkin= ,
ante:do not - darraen - - cam
rents nun , -
M. - 2 systema Outlet -;Y
sddr estli+t,r�o
•
` „10=en • • •ti3' . �.c&- //�"r- .
ZW C(- Teapve Near'
• B. Pumping Record
• (5/21L l' l r - - )566
. 1. Ewe.d pumping oa ';,R.. 4!aritlty Pumped: . Gem
. - 3,. Typdof:system: • IL_Ceaep0ol(5j J—woos iank 0 Tight Tank 0 Grasee Trap
. - • [3Oaur.(desclbe): •. .
. • 4.. Effluent Tee Filter present? ❑ Yee o It yes,'wes it dawned? 0 Ya .
. • C-0(30- . ' •
- .
..- - 8. syaem Pumped By
ty. ) Vats lbws Number .-
oont•CS
• • . 7: Loc9lton where corderdevMM deposed:
t
•
apnene ottieee� ... pk
• Squaws of Receiving Fealty eek .
faorm4.duo 0eae • - arson Pumping Recgrd•Pte I at I