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540 Pump Report o(6//P- 8064i Commonwealth of Massachusetts i. w; � City/Town of :_ #.-t)�tb h a,tital' " System Pumping Record AiFonn 4 . DEP has provided this form for use by local Boards of Health.Other forms may be used,but the Information mist be substantially the same as that provided here. Before using this form,check 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 wthin 14 days from the pumping date In _ accordance with 310 CMR 15.361. A. Facility Information4 Important When meg out 1. System Location: , .•M fomes on the computer.use ori.the tab key Aridness . to move your cursor-do not cnyrram Stele Zip Code use the return 2. System Owner. _ All . 191 C(4mn?&LL t4 Ai ;iS PI i 5LI0 COCES YDhGC ow go Addrpne'tf dMererttemlo I1on) . B. Pumping Record gr.r . -1. •Date.of Pumping © `tti ' r ,..2. Quantity Pumped: aeu re J . Date 3. Type.of system: - p Cesspool(s) ....„2"— eptc Tank ❑ Tight Tank 0 Grease Trap ❑ Other(describe): ( CGTIIYfl tj Y7 I=NT 4. Effluent Tee Filter present? D Yes ../0No If yes,was t cleaned? .❑ Yes 5. Condition of System: -� (}—oop • 6. System Pumped By: Vdtde)cane Number 1:5SiII- hi elk r i-i . 7. Location where contents were disposed: 4 IVS C � Signature of Hinder. -. nate Signature of ReceMrg Facility Dabs Itmk.doo 0.9108 System Pumping Record-Paget yr1