228 Pump Report 5-9-18 . .
. -s. Commonwealth pf MassacPusetti
0 • 4 .: Cityriown of " I -(1'11
ki_
. I. i System .Ptgriping- ecord .
Form'4
,.. .
DEP has provided this tan for use by load Boards of Health.other Tame may.be used,butte
Inforrnagon must be substangally to owns lathed provided hem.Before using ilistrm,check with your
wag Board.of Health to determine the Ion they we.The System Pumping Recoiti must be submitted to
• the local Board of Health or other approving authority within 14 days from the pumping date In _ •
accordance web 310 CMR 15.361. . . .
• A. Facility inforniMion
weAnwrireigt out 1. System Lomita
long ants -
compute.une
only in lab key PS '
armor-do nal . atorawn Stsla . Zip Cada .
unto Mum - .
- a System Owner k•a_
. .
.- .•
•I-. .-- - —5-ts;it. Owrin S • . .
t ..,.( .2. 0, )gst 9...(1 . .. .
Addnps;014:111kantinnn loadlon)
- . .
alyffaan • . 81010 j _
- / • Sl 2 .2-iirebis. . .
•
- . '- 1-Q"-ZO •
B. Pumping Record , . - •
. . • - 1()\021 ,,, 15-6C
. • . A. .Dad Purnbing Debi : - ..og• elYantli PUrnPet
• -.. -
. .
, . 3. Typi.OtersteM: PI Cesspool(s) )3e$&Tau* 0 Tight Tank 0 GreaseTrap
. . .
. " El Other(describe): . .
•
4. Effluent Tee Rfter brined? 0 Ye>?rC tt yee,wee It°Warted?
g. Conciton of System: .
•
. • . .. -
6 ' .
• 7. Locrdlon where caramel were disposed: .
.
. .
• .
- -
. - a
WORM,Of FOICOMW ROW •
.•
8801014.000.OW08 . aletern?mire Record•Pogo 1 all
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