22 Pump Report 6-20201
Important
When filling out
forms. on the
computer, LSa
only the tab key
to move your,
wwr- do not
use the return
key.
Commonweal of MassAchusett8
System .Puri irlg Rec®rd.-
Form' 4 .
DEP has provided this form for use by local Boards of Health. Other fofms may be used, but the
informafion must be substantially the some as that provided here. Before using this.form, check with your
local Board. of Health to determine the form they use. The System Pumping Record must be submitted to. ,
the local Board of Health or other approving authority within 14 days from the pumping date in -
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location: =.
Cityrrown SYete Zlp Code
2. System Owner:Name
�� Gni �l-d2'�• �` ��?? �/7,�
Addreae,(N different from location)
Cljj. QQ'�� (ddd Y,17
b/rown � l � r Jl1l � ' `a 4 �%
ZIP
Roam v Q'� - Talbphona Nundar'
S. Pumping Record
.1. 'Qate.of.Pumping Data `0 :.2. Quantity Pumped:
3,, Type:of system: ® -Cesspool(s) eptic Tank ❑ Tighl
oth a rib f_Co
VAC e
CC -)-0 6)
Gallons
Tank ❑ Grease Trap
ERI CK- H vff2 S .
❑ er. ( esc e).
4.. Effluent Tee Filter present? ❑ Yes, o If yes, was R cleaned? .[3 Yes No
5. Condition. of System:
B. ��Sys\\tem mped By
views' Vehicle Uoansa Number
"c6inpany .
7. Location where contents were disposed: 4-
slghd'ttaeof Hauler. ... Data
Slgnatuts of Reoekdng Fades Data
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