254 Pump Report 5-15-18 i : . .
-+ ' Commonwealth ofssachusetts
_, City/Town of B pli . .
System Pum{iiti record.
Form 4,
DEP has Provided Bile form for use by local Boards of Health.Other forme may.6e used,but the
Information must be aut nlially the seine as that Provided here.Belle wing yitform,check with your
kcal Board of Health to determine the torn they use.The Syt tern Pumping;Record mum submit*to
the local Board of Heath or other approving authority within 14 days from the pumping
accordance with 310 CMR 16.361.
A Facility Informationt.
,
Wien Sling 0„1 1. System Location. .
yap an tn.
computer,
iyttee key Address .
moor-do not Cflylrawa
urthr mean - -
kw. . Owner
1;11 . . . . . .
„jet •Z ,7 G12M1' G-ot-F ctde,
ot_o
witiscin
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.ancti. �jtlsatRab�rpsem ae®me
G 3}rhPTGN T"ewn-"dress
B. Pumping Record 9,0� C
1 rt-( \5 `� ' . Quantity Pooped: Oakes
. .1. 'P6te.of Pum* nO
3. Typ of.syabm: ' piCea®ppol(s) ❑ SepticTank 0 ?ightTalt 0 aaa sTleP
Other cdescdbe) pc-- coI21Y F Tm%NT
4. Forwent Tee F Iter present? ❑ Yea. o t yes;was t ddearied4 .Q Yore ]'I 6�
5. Gorhdatlon.ot System: - .
c009 . VEj I}-tlCIL!
e. SYatem?}�mpad By
WSW tmeeaNumber ,
Ls. Si L wok.
7. LorShcon where contents wade disposed: .
F
Seeable arRmeMlc mei* DWe
Einem Pupae Heamtl•Rice l of t
hapnM.tlav 03/08 -