312 Pump Report 11-1-19 Commonweatth of Ma'ssachus s
City/Town of.
System .P*pin§.Tt600rd
Forth•4
DEP hes provided this farm for use by'loc al Hoards of Health.Other Totms'may be used,but the
information must be substantially the salve asthat provided here.Before using this form,deck with your
local Board.of Health to determine the farm.they use.The System Pumping Record mtfst--be:submitted to
the local Board of Hoeft or offm approving authority*Mn 14 days from the pumping date in
accoidance with 310 CMR 15.351.
A. Facility Information
Impprtaft
1. m Location:When Ong out Syne
forms-on the' -
computer,use
only to tab key Address
to moue your.
of a r to tba refrlrrr do not
use CByrrown stata Zip Code
• '
key. 2. system awrieS
T �
`arum. 3/(9
` ? r°`ddms•(if!dffibr+ent them for;Wkn)
wrown Sim�E I Zlp
til
TW
Options Number'
B: Pumping Record .
4. D.ate•of Pumping . 0A .( . I: L �
Date • D� P�. flattcns
3.. Type.of system: ❑ Ce;ssPool(s). Septic Tank' (I 'Tight Tank ❑ Grease Trap
❑ tither.(describe):
4. Eluent Teo Fllter present? 0 Yes, No if yes,was ik cleaned? ,❑ Yes; Ido
. 5. Condition.of System:
)4,P T
6. ` System Pumped By:'
wagej 1. � ; �,.— Vetdde uaense Number
7. Location where c onleft were disposed: „F
Sight of er. ... t Deb
Signaturs of Reco mm Faofr
WDrm4.doa-.OW0. System Pumpkv Record Page 1 of t