80 Pump Report 2019 A, Commonwealth of Massachusetts
w City/Town of - (11-r Aidstt
i. System Pumping Record' r
_1 Form 4
DEP has provided this form for use by tical Boards of Heel.Other forms may be used,but the
Information must be substantially the game as that provided here.Before using this form,check with your
thelocal Board of local Board at Heal Health or other approving ato determine the form auuthoriy within 14 dayuse.The Sritern s from ttheng R�ping date Imust be nubmiEted to
accordance wtih 310 CMR 15.351. ,
' JS
A. Facility Information
WcoMs ranh out 1. System Location: :'
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B. Pumping Records '
. . 4. 'Date.of Pumping i ,illaA ��1r1 , g. Quarrtlly Pomrped. . �Qers
3. Timid system: Ia Cesspool(s) -SepdcTank ❑ Tight Tank 0 Grease Trap
0 Otter(describe):
4. Effluent Tee Filter present? ❑ Yea 77o if yes,was It cleared? .❑ Ye o
5. Conation.of System: a
C,�C19
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8. ^> Pumped By: .
Vedic*License Number _
ilykw5- 'Sr`L Wyk,
7. LoC8non where contents were aspoeed: F.
INS ?-
signature of Hauler _
Strudels or Receiving Faddy - OS
SyaDem Pumping Record.•Page 1 or t
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