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108 Pump Report 2019 r I C7 / , Commonivvealh of MassAChus s City/Town of system •Pi'lum"pin . 1ecord Fonn'4• ids form far use b •local Boards of Health.Other"'may • DEP has provided � y be used,but the information must 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 System Pumping Record must be-submitted to the local Board of Health or other approving authority within 14 days from the pumping date in - accordance with 310 CMR 15.351.. 9 A. Facility Infortnati®n �$ important: .� When ttlung out 1, System location: forms on the computer,use only the tab key Address I to move your cursor:-do not City/Town State. Tip Code use the return key. 2. Sv emIF S Name C! Cb r-r;�mC Nc {mo AddMw*(f dSiffimrent trom loca8on) city/rown5"tata c ) 0 Code Telephone Number B. Pumping Record ' A. ©ate•of.Pumping Data —�;, . Quantity Pumped: Capons „'1 ? . . 3. Type.of system: [ Cesspool{s} M -Septic Tank" ❑ Tight dank ❑ Grease Trap ❑ Qther{descrit3e}: � 4. Effluent Tee Filter present? ❑ Yes No if yes,was it cleaned? .❑ Yes Pdo ' • 5. Condition.of System: • -�#• ' . . 6. p�Sy�stem mped By:: 0anyVehicle Ucense Number 7_ ocAtion where contents were disposed: Signallure of Hauler. ... Data Signature of Receiving Fardgl3+ Dale Worm4.doc>03/08system Pumping Record.Page 1 of I