41 Pump Report 4-26-18 o7C'/P-Pra-Li.
Commonwealthof Massachusetts
CCity/TownOfe Lt Kt
System .Pum -ping Record.-
Form 4 -
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. . `�•_ DIB'has provided ttda form for use by local Boards of HasMh.Ober forme Maybe used,but the
. Information mint be sithstarleally the bane what provided here.Before using tttla.fam,check with your
local Board.of Health to determine the'brin.they a The.System Pimping Record must be sutmtlted to
the local Board of Health or other approving authority vttttht 14 days from the ramming dela In _
accordance wail 310 CMR 16.361.
A. Facility Information
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vivslegno out 1. syr LOcdOn: ' .
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flay, Mimes , .
ammo Yse. _
nown
Sete Zip Code .
ae.Whoa - -
-
a System owns` .--`
1t in tnCi5211i CrY'rt3 l L
oft "a"°elk gQfucet- I--N'
kloves(atMmsY tam rate
B. Pumping Record
A. Date.of Pcanphig - . C ,}t• 2. Ouan6ty PUMPert . I5 YL
3, Type:ol eYe43m: . El CeeepPd(aj ❑ - rank .❑ rghtTath ❑ Grease7rep
riiO tOttrer.taaeatbe): y- f N1- \fes( j vtat
. 4.. F]Iamrt Tee Feterpresent? ❑ Ysa. o It yee;was!rimmed? .❑ Yes
6. CondtIon.of Syrtem: ..' -
CrOGID
6. Syebm Pumped BY: _ -
_ 7. e w � WildsWildsLanes Naar �_
n�[ ; �- . ? rk • ofS,;.ore •.
Location where Contents were disposed: .
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SpsatsofReceNag Fatly
teomM.aKi Dave syaes oft Pegst