184 Pump Report 2019 Commorrwealt ofsMassachusefts
City frown of.-
. .a
system •Pum',wr igt! io
(Fortin 4 s 6
DEP hes provided this form for use byiocal Boards of Health.Other Toi'ms'may be use "
but the
information must be substantially the same asthat provided here.Before using this•formT check with your
local Board.of Health td determine the form.they use.The System Pumping record must be.submitted to
the local Board of Health or ottler approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.361.
A. Facility Inforfnatlon
.0 nr�lig_out 1. :System.Location:
forms•on the -__` " -" - ._ I -
computer,use
only the tab key Address
to move your. \\
cursor=do not
uSe lila return �
lrown I State, Zip Code
,
key.
2. stem Owrie . c .• :<<
Name. {F :/ o U5( L a Vgo
,'�
Addross'(If.dltterent from!oration)
Cityfrown State �}Ziip.Code/-
Telephone Number
t ' B: Pumping Record
A. Date.of•Pumping 6-a lr-1 c� --�.2. Quantity Pumped:
Date Gallons
r - 3, Type,of system: ❑ Cesspool{s) Septic Tank ❑ Tight Tank ❑ Grease Trap
f; � -
❑ Other.(describe):
4. Effluent Tee Fifter presenf? YesN[] Na if yes,was it cteaiied? Yes []`No
5. tonddion.of System:
' A
• r
l
• a sI j• �. ���,� � ' Vehicle License Number •�, - ,
any .
7. ocatio -where contents were disposed:
40
Slgnttture of Hauler'. ... Data
Slgnature of Rem "ng Facility Date
Mm*doc-03/08 system Pumping Record-Page 1 of 1
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