312 pumping report Commonwealth of Massachusetts
f
.10" - __ : City/Town of , _411-46/174_411-46/1744 n%040.01 .
1' System Pumping Record
Forth 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 Tom,check with your
ltoheelllBoard of Health to ocal Board Healthof or othene the form r approving authority hority withiuse.The System
1�sfr from theping pumping date Inmust be ub ' to
.
accordance with 310 CMR 15.351. _
A. Facility Information
rmparlmt
NRsn twos out 1. System Location:
terns on the
mmpubr,use
oryy the tab Key Anthem .
w move your
°sear-do not CIyn.awn State
use the return
net 2. System Owner. -
1#1111 - TO 111I` STE)(4V,0
Cama
0(t242. c(ftc cion) Fi G cA kir
;Aft Of Afferent from bodkin
City?awn
oy(3t Code
B. Pumping Record b
.
. .1. Date.of Pumping Q �5 t -..2. Quantity Pumped: Gaaww
3. Typeof system: - gi Cesspool(s) )'teptk Tank ❑ light Tank ❑ Grease Trap
❑ Other(descdbe):
4. Effluent Tee Fitter present? ❑ Yes ❑'Na If yes,wss R cleaned? .❑ Yea No
5. Condition of System:
(
8 Pumped Byi�
Lacke,I' S
Silt
W o(k.-1.
'c . Vehicle License Number
sny
7. Location where contents were disposed:
iN SQ
Slphmae of Hauler. _ Deb
Sbnains of Rec ang Fealty Dgb -
System Pumping Reconl-•Pager1 of 1
sbrme.Aov 03/06 -