326 Pumping Report 2018 ., ' Commonwealth of Massachusetts
.,.4 City/Town of �rk�-rh.
'
1 System .Purrrp ng'Record
J Form4
DEP has provided this form for use by local Boards of Health.Other forms maybe used but the
Information must be substantially the some se that provided here.Before using thistoan,check Oh you
local Board.al Health to determine the Tom they use.The System Punting Record must be effimlaed to
the local Board ot Health or other approving authority wahm 14 days flan the pumping date In -
' accordance wlth 310 CMR 16.351.
• A. Facility Information
wn am cout1. System t.aatlon: .
i
tensem the
computer,we
e1n'ne tab key Mean • - - . . .
mayor...
tenor-do not (*raw sdy m0ode
use tbe Mum
SY' 2. System Direr. _ ..
.4;1 - s E 1,LEN 9t?R s- .
Oft r"e3210 cuisieRRFrt&t:D Va
¢aM1eerge anal from balm)
CbyrdeR �y9°s
c.29- 2 t
B. Pumping Recordln .
. A. Date ofPumphri 4 G- 1� :,,2. 4uan94r Pantie* ,�ib1.�.0
' , 3. lypeolaystsm: E Ceespooi(s) J"Sepec Tank ❑ TIgri Tart 0 Grease Trap
.. ❑ Other(describe): . . .
4.. uennt Tee Finer preset? ❑ Vas,�'No If yes:was a dears? 0 Yes f-2' 7�0
- 5. Dominion.of System: - /. ��
CrO°C .
8. _ �yets0n PnanPed By"
'• yams throe Mortar ._
CS 1. crit hJD(k
7: Loc6tlor where content)were deposed: „
SCP-
•
sb+vmseoetimYer. . . vete
sip.tEe of Receiving Falk OWe
laengAoro-owe Sam Pmgta Record•Paye 1 oft