595 System Pumping Report 6-30-20Commonwealth of Massachuvi fs
City/Town ofr-��1Qn�
System :Rcram'p1ng. Recdrd .
For% 4
DEP has provided this firm for use by'local Boards of Health. Met bolts may be used, but the
information must be substantially the; sg me<as ft provided here: Bakwe using this•fonm, chs* with your
local Board.of Health to determine the form.fltey use. The:System Pumping Record must be submPfted to
the local Board of Health or Dither approving authority within 14 days from the pumping data In .
accords= wlift 810 CMR 15.851.
A. Pactttty trtfarniatton
Imporbub-- 1. System Location:
remiewrtlre' — _.
camp
r u"key key Address
to move your.
visor do notCt4y/raam S zip Cilie .
use VA rehsn ' r
owner
yddr0se•prtlltS�r¢6+om Wmtlnp) ' i
awfrmn SUN
S: Pumpirwg Record
:1. ' Qate.of.Pumping Cad. � � C7 � Data Quan* Pumped C�u
3. 1ype:oisystem: (� Cesspool(s) ��Sep0o7ank ❑ 'not ' ❑ GrMeTrap
❑ Other. (describe): CCl7r Yl(�YlL�� l �U
4. Merrt Tea Filter preeeFd? ❑Yes o tf yes, was It cleaned? .❑ Yss 'No
5. /'condition. of System:
l! JM % :Ll C ;
t
8. SystemPiimped By:
o VoN* Lbmo Number
7.LocBaon where contents were deposed:
sighahsea ler Dd4s'.
61giag;iReaeKWFaaNty rate
Womi4.do -Dam system PmnpUV wpb' Pegg 7 ort