167 Pump Report 11-1-19 Common w6aithM-1 f Massachus s
City/Town of �..
Sy
stem .Pump :�Record
Form*4 g
DEP has provided this form ibr use by*kxxd Baards of Health.Other lb ms'may be used,but the
information mush be isubstandally to s nne asthat providpd here. Before;using this•form,check with your
local Bgard.of Health to determine the Tvrm.they use.The System Pumping Record must-be.submiaed to
the local Board of Health or tomer approving authority within 14 days from the pumping date In
accordance with Si 0 CMR 16.361.
X Facility IitforMation
om1.- 'System-Locmdo -
ficrms-on the'
computer,use
orgy Me tab trey Address
to moue your.
wwr=do not cityfrown St ft Zip Code
use to return
may' 2. System Owrigen
Nam,
�6.7 Ma{ FSS 90O
Addraas-(N dWere rrt fom bacal orr)
chyfrown State ' Zra.Code.
U11,3 ' G�
RoRey� Tetaplrane Number'
B. Pumping iRecord
t3ate:of,PuDdb
n:png 2 Quantity Pumped: S
3, Type.ofl systerin. ❑ Oepspaolts}. ' "" '"c Tank [I Tight Tank F1Grease Trip
❑ Other.(describe):
4. Efltuent Tea Filter present? ❑ Yes.' No if yes,was k cleat'yed? .❑ Yes N6
• 5. Condition.of System:
6, System Pumped
RAI
Wass
Vacte tJcarrse Nrunber
f
7. �ocation where contents Were disposed:
• a C.iii{Q e . ..• 4 jdC1Q F
Signal n of Fa ft D*
jMbmr4.docn 03" Pimrpbv Record Page 4 of i