15 pumping report /; :, Commonwealth o chus
- r City/Town of I. 0� `kon-
ki.+� System .Pumping Record
)_ Form 4 .
OW hes provided this form for use by tical Boards of Health.Other Tatem maybe used,but the
Information must be subelatlly the saner that provided las.Bebe using ttds.fa m,ahedcwith your
local BOerd of the to Board oealth to f Health der etermine
bum they use.
14days d submitted1c . .
accordance with 810 CMR 16.961. ,
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A. Faculty Information •
f-
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B. Pumping Record v6
1. 'Date.ofPumping 1pste [.G 1 cY T.,2. ark Pumped: ' .
3.. Type'of system:. C Cesepool(e)>Oieptia Tank 0 Itght Torii 0 Grease Trap
p Other(describe):
t ' c(mprd2?rne -
4. Effluent Tee Attar present? CI Yes Id'No It Yee was a deeried7 4:3Ys , ' C
5. Candtlon.of System: /. P - I'ST-RiC N tfrO eume
}G}{ W13,— l Ftmf k1\; C6{Rp St Ndl et;0 zY NG..,
B. meed By
" `" vert User*Ws '
tic ' S'r`L ��/K .
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7: Location where careen*were deposed: ,.
.. sr psofHeier. ._ . oe.
&pules of Receiving Fa t a,le
faamm4.eoo•MOO System PusPee Rocgd•Peso 1 all
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