41 Pumping Report 6-20-19 Commdnw6alth of Masajachuseft
City/Town of
System •Pi iP-Ir>! ' .-R66Drd .
Forth•4..
3 DEF has provided this form for use by local Boards of Heslth.•C bei foi * be used,but the
informatori muet be substantially the sXne as.ft provided here.Sabre using-thle•form,check with your
local Board.of Health to determine the fprm.they use.The.SyAsni Pumping Record must be submitted tar. .
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351.
A.1Fadi4ity irtforniatioin p
Important
1.
Afton filling out 'System Location: ( r
ibm _Ott the
owiputer,use
only the tab key ' Address
to move your.a ; TO
use ts raturn State. Zip Code
key' 2. stem Owner:
Name
+�* Addr"s-#F difturt from location)
Wrown awe 3 n
Telephone N,mnW
B. Pumping Rekordism
.
s 1. 'D.atca.aF Pumping o . ,. . quantityPumped:
Date, Gallons
3,• Type:Of-system: ® -Cesspool(s) optic Tank �(❑ Tght Tan ❑ Grease Trap
[] tither.(des
crit�e}:
4. Effluent Tea Filter present? Yes,[ No if yes,was it cleaned? Yes []'N6
5. Condition,of System: +� '
,t =- +
6. ' System Pumped By:' C
Verde Uoense plumber
5 l✓/J /
i
7. ' Location where contentxs were disposed: 4-
Slgh"of Hauler. ... Dabs
E%nslurs of Receiving Fad* Date
WomAdocp 03/06 system Pumping Reciad.•Page 1 of 1