14 Pumping Report Ilk Commonwealth of MassItchuselts
C4/Town of
I ke
System P*p1n-0,'* wM
Foam"4
DEP has provided this formi for use bylocal Boards of Health,Other fofms•mirbe used,but the
lnfbffndori musk be substantially the spfrte asthat provided here.Before using thls•form,check with your
local Burd.of Health to determine the iprm.they use.The Sy$am Pumping Recd must be submitted to .
the local Board of Health or other approving authority within 14 days from to pumping data In
ac:cordarx.�s with 310 CMR 15.351.
A:. Facfiity Information
Important
ng
out 1. .System Location:
toms-an the
computer,use
only the tab ley Address
to nova your
wwrL do note. 5tata Cadelow ,
use ft return
' 2. System Owner: ;:=
Name
C4W
•{rf ddrrnnt fon locetEon) —�
Crtylrown state ?T
B. Pun ping Record
'
A. `Dateof,Pumping ' ---- : . Quantity Pumped
DEfte
3., Tom?of-system: � spool{sj Tank C]; Might Tent ❑ Grime Trap
❑ Other
(describe):.
1 #Ur5't
-,
4. Effluent Tele Fitter present? ❑ Yes.allo If yes,was it cleaned? .❑ Yes P%PTa
5. Condition of System:
6. System Flanged By:`
!' ;t. Verde ucsrs a NtMber
r � r
g /
?. Logon where contents were disposed:
sighdf"of Hader. ... t pate
04nidur s of RewMng Facer Data
tBf0 m4.doc0 03!08 ayawn Pumping Re6mt.^Page 4 of 1