165 Pump Report 2019 o,:e!//O-?baa )
1
Commonwealth of Massachusetts
4, c CityR-own Of #, r ,, 0,./ h
;e System Pum*ng Record r
Form 4 -
DEP has provided this form for use by local Boards of Health.Other foams may be used,but the
Information must be substantially the same asthat provided here. Before using this form,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 within 14 days from the pumping date In -
accordance with 310 CMR 15.351.
A. Facility information
Impodent
when sloop out 1. System Location:
forma on the
computer,use
only the tab key Address - . .
to mow your
cursor-do not Gly/Town State Zip Code
urea the return _
2. SystemOwner.
1 . (, 1-P44-EA) t�
Naneles s\i 1 vi cn_n go,Mdroae'ka different mlocation)
ctlymownap Cod.
/ ro 1.'' 2723-s s 9- y/ad
Telephone Nunes
B. Pumping Record
•
• .1. Date.of Pumping 0�ail. -I� ..2. Quantity Pumped: Galion
3, Type;of system: El Cesspool(s) _2-Septic Tank 0 Tight Tank 0 Grease Trap
❑ Other(describe): )- c Ynent-- VC ( mt PKC,
4. Effluent Tee Filter present? 0 Yes f.410 If yes,was R cleaned? ❑ Yesj7ko
5. Condilion of System: _ f
8. -ftystem Pumped By:
Vehicle License Nunber '
Iner timany (S `. Silt wo&k, '
7. Location iere contents were disposed:
Ng
Signature of Hauler D
Signature of ReceMng Facility Dela
Momi.doc 03/08 System Pumping Record-Page 1 of 1