380 Pump Report 2020commonwealth of'Massschuset s
city/Town
Sy$t®m .Pttrrr inlg, ktacord
Form'4.
DEP has provided this form far use by local Boards of Heab.Ober ioims' mqf be used, but the
information must be substantially the ap)ne as, that provided here. Before using this -form, &A& with your
local Board. of Health to determine the form,f" use. The Syster Pumping Record must be submitted to .
the local Board of Health or other approving authority within U days from the pumping data in - '. .
accordance with 810 CMR 15.351.
A. Facltlty Information
1. System Locadon: '
_... Address
aWcywn state aP Cods
.2. System owner.
� �•y-x „-,moi r _
• Addrgse•�dMerent Tramiocetlop) '
_ S , . Tew one Nu mw .
. Fumpino Record
D•stwaf Pumping QuanUly Pumped:
. sasses
3.. Type:of system:. ® Cesspool(s) ❑ SWUcTank-07igfrtTank ❑Grease Trap,
[j Other.(de®cdbe):
4. • Effluent Tee Fuer present? 11 Yes ,21
,y No If yes, was it desried? -E] Yes Nb
5. condition. of System:
VCiu. 'j'W
((Svate„�o
t3. mped BY. To
r i VeNde Lhma Nunber
7. Location where conteriffi were d oposed: {.