615 System Pumping Record 2016 0?U/P-sovp-s,
Commonwealth of Massachusetts
City/Town of
System .Pulrrrping Record -
Forth 4
DEP has provided this form for use by kcal Boards of Health.Olheriohns mfr be used but the
Information must be substantially the sane as that provided here.Before using thlsdoml,check with your
local Board 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 OAR 15.351.
A. Facility Information
rtant
eur 1. System Location: -on the
tear,tea
re tat ley Adams
w-your
If-dome • •- 'own
be reborn -
6i5 giazis PM- Op
ydSBetR dlae,w*tom nmmn)
Zip Cade
crgrrewn • state
B. Pumping Record !
A. Date ofPumping t6 it! : ,2. Quantity pumped; ti e
3 Type:ofsyatem: D Cesspool(;) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe). Oil die1f))( _Co NN Et-T&P lb FP-W 81e-uj
4. Effluent Tee Fitter present? ❑ Yes,[f] No II yes,was It cleaned? ❑ Yes
5. Gory:Non.of System: ' \ -�
C'“300-
Telephone Hunter'
6. nem P}traped By:
t. binik.9744 yeNtle Ucerae tenter
7. Lads on Wre con6ania were tHsposed:
s,oteaedrt ntier.
Stgn m ofRecSsWg Facilj
Worm4.dac 03108
Stearn swiping Hamra•Pena t of t