25 Pump Report 09-27-17 •
Commonwealth of M sachusetts
4, fl City/Town of - rieliG ,
w __ System Pumping Record .-
- - Form 4 .
DEP has provided this form for use by local Boards of Health. Ogler fohns may be used,but the
Information must be substantially the same as that provided here. Before using this fan,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 CMR 15.351.
A. Facility Information
Important
when ono out 1. System Location:
femme on the
computer.use Address
ody the tett key '
to move your _
cursor-do not City/Town Stine Zlp Code
use the Mum
2. System • `r.
lei ,d- [�� oldeF4-1;
� . u�'/ter
Name PS ree`a'"1pp���`` & 9
lldtlreee'(a different from badim)
- OA PrrinpRit Talephur Nipritror
B. Pumping Record
St3VT9-.? 17
.1. Date.of Pumping Date ,. 2. Quantity Pumped: Gams
, 3, Type:of system: - Q Cesspool(s) p^Sepfc Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): b1467 f7w)90 -)- S' `CR Si Vtlu- 71-cit S` 6orrorp
4. Effluent Tee Filter present? d reser io if yes,was it cleaned' .0 vea
5. Condition of System: /. +
(co cQ .
6. fi Pimmped By: _
ov b�JQ3
Vehicle license Number
�.J 'SriL &o(k .
7. LocegonyRiere contents were disposed:
N SOY
.
Slgnsaw of Finder. _ Dam
Signature of Reoet*g Fediy . Dem
elorm4.doc.03/09 SYatem Pumpmp Record•Page t EA'S