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609 System Pumping Record 2016 b o(!✓/P- olJ-jam Commonwealth of Massachusetts City/Town of System Pumping Record - Fonn 4 DEP has provided this form for use by local Boards of Health.Cther?otme may be used,but the information mgt be substantially the we as that provided here.Before using tldafonn,thedcwith your local Board.of Health to determine the form they use.The System Pumping Record must be subintked to the local Board of Health or other approving authority within 14 days torn the pumping date In accordance Weft 310 CMR 15.351. A. Facility Information nt a gad 1. System Location: ,the m,use tab lay nddreee • your do not - . QbRam Muni . . 2. System Kt be9 & U N Yitr [adlaaattom omue atyfrown Ra121S NC.r • T m. rt,&. B. Pumping Re_cord • -0. "D.ete ofPumpin9 f G-.I : - r2. Qpantty Pmpart I Fe 6 3.. Type:ofeystem: - 1E Cesspv )soroyl( ) SepacTank ❑ Tight Tank ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes.L}'No If yes;was It cleaned? .❑ Yes d4 5. Condition.of System: 6. �SyPin stem Pi eV By: t wofk 7. Locelf when cones were disposed: )mk.doc•03/08 YAW..License Number arfae of#amen. -. Signature of Receiving Farms aygan Punphg Rea*•Page t of t