25 System Pumping Record 2016 . o.?V/D-407,lJ---i i
., Commonwealth o Ma husetts
P. ` � City/Town of b7i� C4
At
w System Pumping Record -
- Form 4 •
DEP has provided this tan for use by local Boards of Health.either forms maybe used but the
information must be substantially the sane as that provided here.Before using this tam,check with you
local Boada of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or outer approving authority within 14 days from the pumping date In - - ...
accordance with 310 CMR 15.351.A. Facility Information
11snlung out 1. System Location:
tare on the
only thetann Adams
eery srelaW -
mmwedarr - - - State
cursor-donot r rrom -
use the return fV 2 - t r(-1- 111 0200
cien .Mar e.75 t urrIPAC `Ji"�
*Jaws Of Mea tram lord @) 3Z3"°°25
B. Pumping Record (( ! - 55 C
4. Date of Pumping CJ I 1 l X- -,2. Quantity Pump �oecm.
3.. Type,of.system: ❑ Cesspool(a) �Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
I cum Till LIST -5'Ias. 1
4. Effluent Tee Fitter Present? Yes D No If yes,was k leaned? ,{(y`res 0 No
5. Condition of System: LL��
6. p�ia_1Ped BY' - - -
7. Location ere contenb3 Were disposed:
�\JrCJ�,��✓✓YYJ)
sit
st9rumae of RereNMq F&a oam •
WonMAOO 05/00 - 9ye*m PIM/ft RewN•Pagel oil