145 pumping report o7P/P-41,!/-3i
Commonwealth of Massachusetts
4City/Town of N d th1 a& I
r System Pufnping'Record -
r Foran 4
c,.
DEP has provided this form for use by local Boards of Health.Other time may be used,but the
Information must be substantially the same as that provided here.Blore using ttieform,theft with your
local Board of Health to determine the formthey
.The Sohn Pining submitted
eytod .
the local Board of Heath or other approving the e�Wn7 date .
accordance wtih 310 CMR 15.351. ,
A. Facility Information r•
on out
farms on the 1. System Location:
computer,only thetnk Address • -
to move your
armor-do twl dogmata
Stale . 21p Code .
tee the return
MY. 2. System Owner. -
go e L.L a)[Cm
►q(5 cf-t 1c7t -0 bap
Andean fMenet from butlm)
r mown - • • >.;>� • 617- 7G,i- eda- -
B. Pumping Record
A. Date.of Pumping D � �": . ,2. Quantity Puiiped: 1 aiwa
d L
3. Typiof system: II Cesspool(s) J2'SepticTank 0 -natal-ma 0 Grease Trap
. ❑ Other.(describe):
4. Effluent Tee Alter present? ❑ Y If yes was It cleaned? ❑ Yea$tis—
5. Condition of System:
0. SystemPumped By: - -
Wilde
. i da licenselicenseMNumber _ '
._5-'1
t � hi Ilk
`ClnWry ` rL'L' � .n"
7. Lotion erecontents were disposed: F
Mahahae ofH auger ._ ,
Signalers of ReoeMna Feday - Dab —
ermml.doc.oaoe Syron Pumping Record'•Peas 1 of 1