184 Pumping Report t .
•
A. Commonwealth of Massachusetts
I- • iii ,_,./ City/Town of : t_okikAN-ophAiNc..
System Pumping Record -
: - 1
- Form 4 .
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the
information must be substantially the same as that provided here.Before using this fonn,cheth with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
, the local Board of Health or other approving authority within 14 days from the pumping date In _
accordance vilth 310 CMR 15.351.
A. Facility information , ..,
important .,
get ,,,,•_oem__ ,L.Ois3ua011i-
%sign Nang -i. eys
Semis on the
cenputey use
only the tab key eddies' .
'
to mow your
asses do not CliteTown State Zip Code
use the return
2. System Ovmer: { -i--.
IPC3 E ?01_;2_ 1 rf\t __
EA tg-4 C.6(.ES Y-60613D3Al
eddems gt different tom losaBot)
City/Town ' -----_
StIrtells/hd30 ti ri,• cleri
_tysfii-kplingrw _
B. Pumping Record
SIVI- I/ j 6-0O
-1. Dabs of Pumping ,.g. Quantity Pumped: saws
Date
'•
3, Type of system: C Cesspool(s) „.21"---Septic Tank 0 light Taojc 0 Grease Trap
g'-e-CiinQr4(411VNI- OLD Tice')
0 Other(describe):
4. Effluent Tee Fitter present? ' Yes D No If yes,was it cleaned!...2-'6--s a No
5. Condition of System:
S. rfnciVed BY:
Veit*License Number
tri _
7. kx:atl v”. e contents were disposed: 4.
W‘15 _.'.‘"
Signature at Hauler , Date
)
Signature of Repaving Feat Ws
OfOrrre.dom 02406 System Pumping Record•bags 1 of 1
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