120 Pumping Report ±Z, Commonwealth of Massachusetts •
d p City/Town of iUG^,` A "
1 System Pumping Record
Foran 4
DEP has provided this form for use by local Boards of Health.Other nouns may be used,but the
Information must be substantially the same as that provided here.Before using this Tom check with you
looal Board.of Health to determine the form they use.The System Punpkg Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in -
•
accordance with 310 CMR 15.351. .
A. Facility Information
Whe
on mpgour� 1. System Location: '' ' ^
romp on the
computer,use &kl
only the tab key
tomove your —
cursor-donot arm' Stets 71p Code
use tin return -
kw 2. System Owner.
Cr C ,SU0QIS
Ottt o cbE; Inns=to-owgo
Itr n.0 A.derea'M clement tom jtw,)
City/raven -ele.n. `1-1-. Zip Code S--)
oz- 'PeCT SiVc N -
B. Pumping Record t
• . A. "Date.of Pumping is- <:2. Quantity Pumped: . `-�
Gallons
3. Type:of system: . � .Cesspool(sylSeptic Tank 1:1 light Tank El Grease Trap
` ID Other(describe): A-Crxnen-r-"Jll TrnPiS1 ') CUD nee
4. Effluent Tee niter present?X res 0 No If yes,was It cleaned? . Yee ❑'No
5. Condition.of System: -/ _t
C )OJ
6. System Pumped By: ,
"
1 .1((007171 Vehicle Lime.Number _
y ts Slit wolk,(44-te .
7. Location where contends were disposed: 4-
W\ S
W\ S ?
SIgnebee of Hauler. . Date
--
Signature of Receiving Fater 0
taonrM.dom 09106 system Pumping Recde•Page 1 of 1