Loading...
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