183 Pump Report 5-15-18 •
;+ ' Commonwealth. Qf Massachusetts
. ' 4 City/Toyal of IV 07474,;(411-441 .
iiLSystem .Puitiping' tecord.-
�. Fonn 4
DEP has provided ells form for use by Iowa Boards of Health.OlberTofl may.bowed,but the
Information must be 4'the eyne ea Mat provided here.Before using ttib form,died(with your
local Boamtof Health to determine the'form.they use.The.System Pooping Record must be submitted to
the local Board of Health cc other approving au horky within 14 days from the pumping date In ,
accordance with 310 CMR 15.351. -
A. Facility Information
• . 4
wilt;Inn%ore 1. System Location: - "d`
tenne on the •
•
m mora yore.
omr:dono[ 'awn own Stets Zip Cala
kW.um -„r
.2 Y�iH �� CII>Lf\
clith g'3 s l v Gcsi-e . 62A2.ednmeidibminttombadbm
• • Clynbwn 3- vcy °/ .
ric� (Le- NCk` . `,, .reap.
. B. Pumping
PrnbRqecod . - .
1
p �x, :, Quemoy Ptrped:
oafs
3.. Type;oPsytstem: • Ill Casepool(s) f]-sepacTenk D ?ightTer& 0 Grmee.TYap
❑ Qatar:(deealbs>:
. .
4. Mani Tee Filter Present? ❑ Yse.' o tryst's/as k dossed? ❑ Yee f1N6--
•
- - 5. nGQ_ard,isi d'cSystem: r - -
n matt' t. ct t I �d �;✓iI i.t .. yams Lions Number _
- 7. �Loi too vyltere confetti Were disposed:
U �,6\1I/J')
Sbnesae oftiaer. ... . . .
Swan of R.csVae Fad* •
OW
emna'1Aop oatos Osten Pumping Racptd.Page 1 ort