203 Pump Report 6-17-19 i
, ' commgnwi6alth of,Mas'sachuseft
City/Towh of.-
System P n l>n•g ROODrd.
Form•4. ,
DEP has pt`ovlded this farm for use by'local Boards of Health..Quiet`fidhns'may be used,but the
Information rnu9t be substantially the spline as that provided here.Before.using this-form,checkwith your
fool Board.of Health to determine the farm.they use.The System Pumping Record must be submlttpd to. .
the local Board of Health or other approving authority within 14 days frim the pumping date in
acoordan ce with 310 CMR 15.551.
A. Facility Ilnfolmiation Y'
"en tmni;out —1. 'System ca
-Lotion:
ferms on the +"
computer,us® ~
ordy the tab Key Mdrws
to move your,
cursor L dono# Cigdt"awn 5#ate Zip
use the return Cade
My. 2. stem Owner:
Qr`r .ct CQo-w�
Name " G-
, "
+�
Ad&"s*(W&Mmtfrom iocaation)
cnyfr
el
- _ -�'i•-•,Qf 1�,(��� TeleRlwne Ntsnber• '
B: Pumpinig 11e4ord
. .. � • cam..`�. �,'� •� • l)Z) ,
A. Qate.of.Pumping oar uIP 6d,
3, Type:of system: W Cesspool{s) SeptIcTank ❑ Tight TanK ❑ Grease Trap
❑ t Cher.(describe):
4. Effluent Tee Filter present? ❑ Yes; No If yes,was it clearied? .❑ Yes No
5. Co
ndition,
of System:
6. . .mped By`
Vele L.laerza Number
.. rw
7. Location where contents Were disposed: ,
sighOure,of Hauler
Signature of ReoeMng Paaft Data
WorrnCdoc-031t)t3 system Pumping 12e6ord.-Page 1 or 1