46 Pump Report 5-9-18 •
Commonwealth of Atlas:
• City/Town of - 11/-tuilinKTITelk
" System .Puniping kecord
Forth 4.
. . _ DEP has provided this form for use by local Boards of Heal t.OlderfoMp may.he used,but the
Information must be eub0tandaiy the apse as that provided are.Mae uetng tlds:fbrm,chedcwith your
local Board of Health to determine the form they tat The System Pumping Record must be submitted to
the load Board of Health or other approving authority wain 14 days tom the pumping data In _
aceardanre wlhf 910 CMR 15.951.
•
A. Facility Information - a
aut t. Syatam Laceton: .• :
fame aethe
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computer, foe
aie
anyyatr hearth -
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weer*not
Ah
ueasem � � " - Ste Dom
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2 System owner.
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I-1(p YF LL RFD G€ a 2n,
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Clay/ram •
B. Pumping Record
l'L,
.1. Date of Pimping l 0.10 ;�G 1 6 2- Quantity Purpau µesoRs
9, Typa'olsystem: P1 Cempool(s) —Sepucrenk El TIghtTanc ❑ Grease Trap
. - ❑ Other.(describe):
. 4. Effluent Tee Flfter present? ❑ Yes. Iryeq"wes a dearied7 .❑ Y
5. Candton of System: -
(1-136C)
tr.: 1:s `• 1tm &t _ ye .uaae.ra.rosr
7. Loc6tionwbere corderihhwee deposed: - .
•
sand..orileaar: .: oea
Striatum of Rambling Faaib oar
erOmMAoc.Dema - _ araraa Pumping Rad•Paw 1 01