120 Pump Report 2019 �I/V
Commolwwalth of M4assachuse�ts
Cityrrown of N 6 r m, Atr�-
System :P*oIn•g, Pe;dord
Form 4. ,
DEP has prodded this form for use by'locil Boards of health.Other fohns'may be used,but the
Information nRust 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 Systeml Pumping,Record must be submitted to
the local Board of Health or other approving authority within 14 diys from the pumping date in
accordance with 310 CMR 15.351.
' A. Facility Infomigition
•7'
When Ong out 1. System Location:
- --- -fnmms on-the- - --- -- --- - -�
' computer,use -
only the tab key Address
s to move your
cursor=do not C*ITown State Zip Code
use the return "+
`' 2. System Owner:
" 1elalo coC *
+n Addrps•(f€dWerm t firm locetlop)
CILy/Town State Zip Code
Telephone Number'
B. Pumping Record '
" I
.1. 'Dats.of Pumping beifte C 2. Quantity Pumped: �Gallons�
3, Type,Of{systetxi: ❑ Cesspool(s) �epttc an j❑ T ht Wank ❑ Grease Trap
❑ 1 .
Other.(describe) J1 tLl G�7V�! O CO
4. Effluent Tee Filter present? es.❑ Pio if yes,was it cleaned? Yes ❑ trio
. 5. Condition.of System: +`' P),
<7eITop— `Xac 96TTgrrk
6. Svstern nmped By,
Vehlde license iVumber
c l D�
-4
• any . �,
7. Loc gMo i where contents'were disposed:
SJgn _ of Hauler. lie
• 3
Signature of RecaMng Fadltty Dale
t9f4rrn4.doc
03/06 System Pumping Record-Page 1 of 1