165 System Pumping Record 2016, - commonwealth af Massachusetts!
City/Town of - ffc-4114,45449-M- .
System Puniping' .
Record.-
Form-4 .
DEP hes provided thla torm for use by 1=113°i:try's of Health_Other btries msg.be used,but the
intimation mist be atthalantlally the!erne aa that provided hare.Before atm;Nam%chedc with your
local Boardof Health to atermine the lorm they use.lhe.Sydem Pumping Re:o/dmut be submitted to.
• the loot Board el Heath or other approving audio*within 14 days tern the maiming We in _ '
addattande with Ma CMR 15.35.1. •
A. Facility Ifferiniation
t-
ngate 1. Einem Loodont
the.
uie
gb ley Mimes •
10 not alyntee
3 , . rrpt2- .4(41 165 Gu,kkows-ri
Zip Code
B Pumping Record
catwoiPenrea cuaree PURIM •
3, Type:Ci system: WI esespoolfej • p‘ple Tank 0 light Tank
D. Other(describe).
4. Effluent Tee Filter present? ci Yee No If yes,was it cleened7 0 YeafP16."--
• 5. Condition of Eyeflent
OKI
GOOFS
0 GISMO TRW
cow
7 •Lsoceton conferisWens
a(1)'
3Ignalos of Regd./dig FBA*
form4AM MAX
VMS Unease
Syelli Pumping Pecgra•Page i or'I