330 Pumping Report .g: ., Commonwealth ofhlaasachus ,etets
City/Town of - /(4_//11,Wee/7
; System PumpingRecord
i
4 Form 4 _
. .i.
DEP has provided this fomi for use by local Boards of Health.Other btms may be used,but the
• Information must be substantially the same as that provided here.Before using this tom check with your
local Board of Heath to determine the form they use.The System Pimping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 910 CMR 15.351. . .
, ..4
A. Facility Information
Wien out 1. System Location: ' 4
toms on the
computer,use
only the tab key Address .
to move your
cusor-=
use the Mao" State Zip Code
kW-
0 2. System Owner :7t
0%
- inr1 D-. -5C (4), ofiqci '2'
b . .
Name ,
33o co(CsTheeimA c4)
Addrossof Moment tom bcallop)
Qtyfrown .
. ripain:mteri-Ct.\(iR\')Aptst-niQ12,11 -
B. Pumping'Record -
•
OrTV • \g- . 2. Qua i °°°
4. Date of Pumping ray Pumped: osions
. ,
3. Type of system: fE Cesspool(s) .j..X Septic Tank 0 TightranK 0 Grease Trap
C Other(describe):
4. Effluent Tee Filter present? d Vs:014o If yes,was It cleaned? 0 Yes.„013O
• 5. Condition of System:
62061) •
6. racedBY: ,
Wide a
L.5 -51 t License Number
i w . _
7. Location where contents were disposed:
4.,
SighSturs of Hauler • , Date
%mauls at ReceMig Faces
Storm4.clos-03/06 Sargon Pumping Record•Page jot I