11 pumping report SA, Commonwealth of Massachusetts •
w .' City/Town of " N'p L-ft,M'y-a .
" System Pumping Record -
Forth 4 -
DEP has provided this form for use by local Boards of Health.Other fohns may be used,but the
Information must be substantially the same as that provided here. Before using tie form,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 910 CMR 15.351.
A. Faculty Information
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vfiem mug out 1. System Location: - '
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2. stem Owner. 1 -
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B. Pumping Record
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1. 'Date of Pumping , �H ,2. Quantity Pumped: . / on
. 3. Type:of:system: C Cesspool(s) ...5.1--reptIc Tank ❑ light Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Fitter present? ❑ Yes..- o .If yes,was it cleaned? .❑ Yea
- 5. Condition.of System:
e. Systgpl,pitmped By:tawkKeny _/
L 'snit �IiO&4 -i . Vete Llano Number
7. Location where contents were deposed: de
IN E P-
Slots of Hauler ' Dab
—
SIgnalre of Receiving Foggy We
teemn4.d00 09/06 system pumping Record'Paine 1 cal