421 pumping report of f ia- fizrj)
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14 Commonwealth of Massachusetts
w City/Town o - �U tic. . f' jN
;"i: System Pumping'Record - -
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DEP has provided this tam for use by local Boards of Health.Ober Tons may be used,but the
Information must be aubslantlal y the Larne en that prodded hero.Before using Ins.fam,chedcwith yar
local Board of Health to determine tha?am they use.The System Punting Record must be subtitled to
the load Board of Health or other approving aulhodly wino 14 days from the pumping date In - . .
er a:Mance with 310 CMR 15.351:
A. Facility Information
yasw out 1. System Location: ..
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forms anta - ..
an
orly the tab keY Mdrea .
mmwanur. .
weer-da not .OM,,, EOMs Zip Coda •
us Os return
�. 2 System Owner. l _-
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rnn443 12,0
mom-(VAlh'artSem Sagan) /,
eros
B. Pumping Record .
. -1. Date:Ill.Pumping o.2- Quart*Pornded: . cora.
3. Type or system: E.l Casspoo!(s) ❑ 'SepdcTank 0 Tight Tank �'6ro°80 TAP
❑ Other(desists): .y .
. - 4. Effluent Tee Fllter neem? ❑ Yes Olo M yes,was a cleaned? 0 Yee ld'No
. . 5. Condition.of System:
U�
G6cs) ,
B. System By.
'l viae license ones '
7: Loctllon where cordate wad deposed: 4-
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£uia ecf.Hger. ... _ ori.
erwnn of haeme'•FSLS, tiM. -•
JCrm4.dar MOO syln Prgptg aocprd•Pegs 1 or 1