96 Pump Report 2019 . t,7r//0-hDlJsi
SA, Commonwealth of Massachusetts
d City/Town of - Al a_E4 ere-lort
c,_
1 System Fum'pingiecord
!/ ' Form 4
DEP has provided this form for use by local Boards of Health.Other lathe may be used,but the
Information must be substantially the same as that provided here.Before using fds.font,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 wlthln 14 days from the pumping date In -
accordance with 310 CMR 15.351.
. :.IA. Facility Information .
bljtcnirca Gut 1. System Location: • '
fermi on the
ter, I
onlyI .
qty tie tabb ley Moses • -
to move your.
snot-do not ,Rw,,, able Zip Code
use to rotor
�
� �'' --n 5 2. System Owner. .
ru=--u cl4 fl PPE
q(° COWS MET)-10013YZP
M3ece'ef deferent from IocJbn)
ary,raan • • /2• Cr t).3 ifird") •
ROZ'114 i-mp`i Ta ap wre"a t°
B. Pumping Record �� 1"
.1. Ode.ofPumping l `'{-�Das —�' 4, .2. Quantity PhehhPed 1Odors
50 0
3. Typeof system: E Cesspool(s) tic Tank ❑ light:ank D Grease Trap
❑ Other(describe):
4. Effluent Tee Fitter present? Yee 0 No If yes,was It deened2jitis 0 No
5. Condtsan of System:
8. yat mmped By: A )�` �,, �.
diel Y L , Stift �Y o/k,✓a/''e" . WINS License Number _
7. Location where contents were deposed: M
S hflfl Ofkmder. ._ , Oats
signature oReceiwq Pea - Data
wemn.dao oaroe system Pumping Record--•Paget al l