133 PUmp Report 2018 . . °Willa- vales)
.IZ, , Commonwealth of Masssehusetts
4 City/Town of _ N ,01•+k_' ,,,,(t�/ `�
1 System Pumping ectd.k
l Form 4
DEP has provided this firm for use by load Boards of Hewh.°ibirTahm may be used,but the
information must be substan hly the sane es that provided hat Before ting tld -bm,check with you
local Bond of Heath to determine the farm they use.The System Pumping Record mut be submitted_ta
the local Bond of Health or other eppmvng etehody within 14 days from the puna);date in -
accordance with 910 CMR 15.351.
'
A. Facility Information
rAfT,,,,"r4 out 1. System Location:
bre on the
canputer,use
mn�e1
la theT do not ObvrieR able ��
use the ream - .
�. 2. System Owner _
/J ST63NisLwsKL : �6hn.
gm Snel33 Ni2E
ENTus hie1i) 624Q
*ism nhanfine bac")
B. Pumping Record
. .1. •Date:otPumping I : .,2 Qam9yPumped: •) 6C .
S. Type:of eystem:. p Ceaspoats) iaiiepticTank 0 Tight Tent 0 Grease Tap
0 Otter(describe):
..3.4.. Effluent Tee Fite � No
present? 0 YM yes,vas It deemed? 0 Yea - No
- 5. Condition.of System: .i
Clo 0l'ii) ,
6. 7
Pumped By:'
�U63
_
Ir�� �
•
L l�✓0/<\!✓4I1 . Wide i,�..Number•V Slit .
7. Locationwhere contents were deposed: -
i'
V S1F n .
SfaeeGee d}iever. ... ads
Signature of Receiving Fedy Deb -
•
rormi.doe•aorta sen.Pmc c Resew•Page I eft