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203 Title 5 Pumping Record, 2016 A, Commonwealth of Massachusetts Cityffown of System Pumping Record - Form 4 DEP has provided this Tani for use by local Boards of Health.Other forms may be used,but the information must be substantially the same as that provided has.Before using thisfam,check with your local Beard.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 rve�ien sang-ad 1. System Location: felms on the • computer,lie only the tae key Address tonerieyour - -cursor.-do not • Shy/Town use the retain - 2. rctem riciek LT_ twXt Uform4.do • N 9-3 fl')FLC 6ZV� 6ZQ Afire a'gt(eweren tom"Cop) atyirwm B. Pumping Record . stets Telephone timber �Y111`�3lfo 15-6 -1. Pate.of,Pumping •-,2. Quantity hrtped: Getoma 3, Type:ofsystem: - IC Cesspool(s) pilep&Tank ❑ Tight Tank ❑ Grease Trap - ❑ Other.(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was It cleaned? ❑ YesrNo 5. Condition of System: ✓ S. : S -_P mped By: s1 7. Location where dwntenb3 were disposed lV J Wilde License Number Gowns°of Reuter ... Signature of Receiving Fadfipf system Pumps®Record-Page 1 of