28 Pump Report 2019 t ,
Commomcialth of MasSachuse#s
- Cify/Town ofd
System .Pl OW1ng.AWdo- rd
Form' .
DEP has provided this form for use bylocal Boards of health.0tber'fotmst maybe used,but the
lnformaUori must be substantially the sine asthat provided here.Before using this•form,check with your
local Board.of Health to determine the forrn.they use.The System;Pumping Record must be submitted to
the local Board aP Health or other approving authority within 14 days from the pumping data in
accordance with 310 CMR 15.351.
A. FacIlItf InforMAtlon
wfhen jou ng out 1. System Location:
- - - —forms on the' - —— - -
computer,use
only the tab key Address
to move your,
cxrrsor=do not Ctgfrown State,
use the return' Zip Code
'
key` . 2. Syxtern Owner. t==
' Name C7''� ���u v �� �`�' °��` • ��,�.
Add '(If dftret t from location)
cWfrown St$ta Zip c
� - �5 ogl
9 - Telephone Number'
B. Pumping Record '
+ .1. Date.of,Pumping g G2uantity Pumped:
Data Gdons
3,• Type.of-system: ❑ •Cesspool(s) �A" ep c Tank' ❑ Tight Tank ❑ Grease Trap
❑ titter.(desc rlbe):
4. Effluent Tera Filter present? ❑ Yes l-No If yes,was it cleaned? .❑ o
.Y!s/❑.
5. Condition.of System: # = ,
6. mped By:'
NameVehide Ucqnse'Number
• •. `' j � Gil���":��b'�--� . •'�`���' � - `.��• •
any . .
7. Loc9Uo ere conteft were dloosed: °
T11.
Slghkire of Hauler. ... Date
Signature of Receiving Fad(lly
t6fgmpl.docy 08/08 System PumPIng'Record=-Pago�9 of 9