421 Pump Report 3-20206
S
when f9ang out
thnns'on the
_..rbmpu�r�use
Doty the te6 key
to move your.
anew: do not
uea Qts rrtmn
key.
EM
Commpnwealth of MassgchusWts
City/Town bf
Sy$tem .Pt!Mpin§. Record.
Forrn' 4 .
DEP has provided this form for use by'local Boards of Health. olhef thus may be used, but the
Information must be substantially the same ass that provided here. BsIb4 using No -form, dwx* with your
local Board. of Health to determine the form.they use. The Syatsm Pumping Record must be submitted tQ
the loom Board or Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 18.351.
A. Faai&Ity Information
1. System Location:
2.
Address
Coyfrown Zip Cade '
dgrRown sme � ,, �c
A. ' D.ate.of,Pumping
3,. Type.of•system: ❑ OWSPooKs)
2. Quantity Pumped: .
❑ -Septic Tank ❑ Tightiank
FSU
Oerone
reale Trap
❑ other. (describe):
4. , Effluent Tea Filter present? ❑ Yes , No if yes, was it dearied? .❑ Yes�o
5. i .andition. of System:
7. Location where contents Were disposed:
A77n, —
9lgneturs of Rsoeh" Fac ft
�omraaov oaPoe
value Llamas r M*W
system Pumphtg Record" Page 1 Of 1
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