39 pumping report cel//0- Pj)
Commonwealth of Massachusetts
14 City/Town ofof
System Pufn�g Record
1 Form_
DEP has provided this form for use by local Boards of Hee th.Otberfohns may be used,but the
Information must 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 within 14 days from the pumping date In - '
accordance with 310 CMR 15.351.
A. Facility Information
Important. - -
when smoggg out 1. System Location: `'A
fans on the.
computer,use
only the tab key Address
to move your -
anon.do not Clty/rown Stele Zip Code
Lee the Rani
kali. 2. System Ovmer.
e 3 `l COUT 71� UJ)444
Mdece'(If dife,ent from looallon) y/��Z .y�qo
�'(Cayn'awn • 27: 3 Z�/r -Z fi �
_ - -Cal 5\c-e TeISphmte NunlEx .
B. Pumping Record [�
4. Date of .D.b `� - • ,2. Quantity Pumped: JGU .
3. Type;of system: El Cesspools) Ileoflc Tarek 0 light Tank CITr
Grease ap
. ❑ Other(describe): . `
4. Effluent Tee Alter present? ❑ Yes No If yes,was R cleaned? .❑ Yes/12 No
5. Conddion.of System: "r
6. System FAimped By. • -
�� � Whitt license Number -
term
L' `Slip- byofk •. _
T. t,pcetron where contents were disposed: 4
Skjheture or Hauler. _. Dab
Signature of RecehAng Fedky Data
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