146 pumping report 9i, Commonwealth of Massachusetts
City/Town of Vik444,99tOt
System PumpingRecord
. ,o Fonn4 -
DEP has provided this form for use by local Boards of Health.Other?ohms may be used,but the
Information must be substantially the same as that provided here.Before using tits form,check with you
local Board of Health to determine the form they use.The System Pumping Record must be submittedto
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.951. .
A. Facility Information ;.,
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Offing ad
out 1. System Location. -
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orly p use key Address . .
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IOW 71p Code
System Owner.
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B. Pumping Records n(-c%f 1 CC
.4. Date-ofPumping - __d .:2. Q!harhtltY Knee aewr.
, 3, Typeof system: - ill Cesspool(s) o Tank 0 Tight Tank ❑ Grease Trap
. . 0 Other(desaibe): -
4. Effluent Tee Filter present? ❑ Yes o try wes I dewed? .0 Yes -t0c
_ _ 5. Condttion.of System: r
Rop .
5. S_c!erAP}(mPad By:
6�v���G 6W�11 Wilda time Number
an LS `StiL wo/k,
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7. Locidlonere contents wee deposed: f
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Sffindure ofRerephlp Fear Dm —
1formd.daa 03.000 System Pumpkin hooped•PWe t m 1