157 System Pump Report 6-30-20Commonwealth of M ssEhasrfs
City/Town of 2
Sy:stem :PliximpTt 6 Record .
Forl><t 4.
DEP has provided this fomri for use by'locel Boards of Health. Otl)er fohns' may be used, but the
inforfndori must be substantially the so -me :as. that provided here. Befor+a using this•fom, check with your
local Board. of HesM to determine ths form:they use. The Systsm PumphV !record must be submilted to
the local Board of Health or other approving authority within 14 days torn the pumping date to
accordance with 810 CMR 15.851.
A. Faciilty Infotnitttion
Wfian out 1. System Location:
..a
camputsr, use
0* tlae tab key Addmw
to move your
aeacT-do not rwn SW app .
' Ufle fba Ialum _ .
'2. ST-�y-s�teM O�wner.
Name.l5 7 C� I�t`Ci21 h L� b
AAdMM*(ffdffarWtfromWceeap) .
• Cilylrown ante . �V •� Zlp Code
- � S Tal§phM�e Nun6eri
B: Pumping Re+pord
CSU0
,.1. D,ets.of,Pumping DflmF. a. Qua * pumped:. gfl9oss
3... Type:of-system: ' f 7 •Cesspooi(a) SepticTank D Tlghtiank ❑GreaseTtap
❑ Other(describe): .(• - S 7}12 L i
•.
4. Effluent Tee Filter present? n If yes, waa k deaiied? .0 yes No
5. Condition. of System:
-f-A 1'04_
8 Syst's Pumped By:
hl
7,
YoW* Uoazrae Number
_► �
7.Logon where cordeft were disposed:
StgHflhae of ar Data
S�na#ure of Rece[Nng FflaNly Dasa
t�gGtn4.tloa 08/06 8ystam PumplM Racmd • Pagel ori