421 pumping report (2) 0.(!//U- 17-0j)
Commonwealth of Massachusetts
cMk / City/Town of _ ,�-y (-��
System Pumping R�LQ�rd
Form 4 _
DEP has provided this form for use by local Boards of Health.Other forms may be used,but the
Information must be substantially the same as that provided here. Before using this form,check with your
local Board.of Health to determine the form they use.The System Pumping Record must be submMed 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 ',
*Importany
v4ien filing out 1. System Location: - �i
forms on the
computer,use
only the tab key Address ,
to mow your
°sear-oro not gyfrown ".tele Zlp Code
w the return
la 2. System Owner:
b0 . VA Th L of c-n-L Cl rot'
name d, °milk, 6z0
Address Of different tom lois°)
Cmytrown . stab zip Cade'
1..(1> PS re ewe» k,ne.
B. Pumping Record • 000
D
-1. Date.of Pumping Oct �� i ,..2. Quantity Pumped: Goons
3. Type:of system: - 0 Cesspool(s) ❑ Sepftc Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was It cleaned? .❑ Ye Z Nc
- 5. Condition.of System: -�
C Pvyll c>4zeos: Tow - ,
8. System Pumped By:
Vehicle License Member _
t:52251r<t Gdelk
•
7, Location where contents were disposed:
NS PT
SlgnMeea of Hauler. ._ Cab
Signature of ReceMng Fuggy Deb
leprm4doc Oa/0e System Pumping Record.•Page 1 et 1