320 Pump Report 4-2020 (2)Commorrvuealtf Massachuseft
✓ Jf
city/Town of; �y Gam`
System( p _kora
Form' 4 ,
DEP has provided this tori for use by'locel Boards of Health. 0 bft maps be used, but the
intotmadon must be subvtanda6y to same as V* provided here. Bef m usft Ns•tomt, do* MM yotr
local Board. of Heart to determine the form.they use. The System Pum0 tg Reowd md"at-t a subm"d to
to local Board of HOM or offer eppro ft aulho.* wdhin 14 days from the pumping date in
ac cordanc:e wrath 810 CMR 15.551.
X Facility Informittion
won MW out
1. System Looatlon:
to maw y ur.
as do not
R•� tom. Zip Cam
uee the Mtum
keY•
2. Ow77 ner. ��'���p
gdd�e Qf ap;w om Woaaon)
S. Pumping Record
1. ' D,ate.of,Purnft 2. 4uan* Pumped: < oeeu+e
3.. type.ofsystsm: ' ❑' !fe)_-SWWTank ❑ 11gMTank ❑ OreaseTrap
C61774%i-gf7nL
ptf,an(d®scribe): •ALL'
4.. eMluWt Tee FHtsr presettit? ❑ Yes Id No H yes, w� ft dearied? .❑ Yes.PIN6
5. Condition. of System:
•
��JotO
,
syso'em .
Y u t
7, tarvy�tere canimrtte were disposed. ,,
�Aghaaor er. ... �
�. .. •
i
.:
*ndm of ReNMM f1kOW DOS
S �P�P �, d �7 M i
}�tn¢.daa•
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