31 System Pumping Report 6-23-20c. a
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)e i =fitC Cityrrownof
Msystem Ptopg,Retzrd
;'4FollOt
DEP has provided this form for use by local Boards of Health. Other fohns' may be used, but the
Information mud be substantially the same as. that provided here: Before using this•form, check with your
local Board. of Health to determine the form.they use. The •System Prmtping Reocrd must be submitted to.
the laced Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.951.
A. Facitity Information
Vldhen Ong out 1. ' System Location:
iemhe an the
computer, use
only the tab Key
to moue your.
visor =do not
use the return
Address
CRY/Town
COW
State Zip Code
yddreSs•rir tltifererR hnm locaaon)
OWITown Stat® 22p.Cods - .
0 ce
Telephone rtisnbef
S. Pumping Record
I
J 6(YJ
M.
Date of Pumping -^
Dahl
2. Quantity Pumped:.
Gas"
3,_.
Type.'e system: ' Ya Cesspools) SepticTank'
❑ TightTank
171Grease Trap
h 4.
❑ other. (describe):
effluent Tea Filter present? ❑Yes .' Pio
if yes, was It cleaned?
:❑ Yes No
5.
Condition. of System:
B.
System` Pumped By.
—
Vahida Umme Number
7.
Location where contents were disposed:
Sighdhne of Hauler
Data
U
.
Signature of Receiving Facility
Date ..
., .
tftrm4.doc^ 03/06
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system Pumping Recgid • Page 1 of 1
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