599 Pump Report 2019 . 0.{P/0-PoPj)
14 Commonwealth of Massachusetts
9 ./ City/Town of fOs if--tL4ri °-F24j
� System Pumping Record
. Form 4
DEP has provided this tom for use by local Boards of Health.Other films may be used but the
Information must be substantially the s se that provided here.Before using tds tam,check with your
t��Board
ath ro d approving or other hey use.The System aurora/wain 14daysPumping RecoM must be a the pumping date InubmlFted to
accordance with 910 CMR 15.351.
;r
A. Facility information
� It;out 1. System Location: 1
e on
computerwiythe r,we
u e . -
to 1110W your.
weer-do notw,r, arae Zip cam
use the velum
MV. 2. Syetec owner:
cjitar' 5''rcl Co rAe 000w .120,,
deers drdeferent from boa#)
` !roan , SDS - ` ;:74- 3 '
k)mat-1 trf)PON - . Te1epioir Niieer
B. Pumping Record
\17it1 lig -tel. ':Z. Quart P(m pact
1566
A. "Dete"dPumping - owe
3. Gloom
. Ttrpe fsyebm: 0 Ceeepoal(s) <Sep�Tank 0 Tight Tani( LI Grease Trap
❑ othec(daaa+bet: 9--COMP Narni€Ni cow Tye ') ur-ay \
i ft
4. Etuerd Tee Filter present? ❑ Yee No if yes,was it dered? .❑ Yas7a to
5. Condition.of System: - +
6. System Pumped By:
O�tioo") ydede Loots Number
7. Location where contents were deposed: 4.
C ( '
swan at Hauler . ,
SIgretUre of Receiving Eta - -
' aides Pumdre Record•Page 1 of 1
arwnM.tlaw 03/06 _