28 Pump Report 2019 r,lC//U- U1
•
SA,, Commonwealth of Mapaachusetts
r; City/Town of 0/141,fiviceh
r. System Pumping Record -
Fonn 4
DEP has provided Es form for use by local Boards of Heetthl older lams may be used,but the
Infamdal must be subetantldlY Ms are r that PrOVIded here.Biskra using this.fomi,check with your
local Board of Health to de0armine the fonthey uTeen em Roping
from Re ecord
rdimtst be ng date isubmitted to
the logs Board of Health or other approving authority
n
accordance with 310 CMR 15.361. ,
ti
A. Facility Information
,Min ®ad 1. System Location:
Rene on the
use
oral the
computer,use
Addle" , •
to move your SOS
°esor-do not . cforrawn
. 21p Cade
use the mean
Z. lan
j t28aeJ kt
� ` qaN
'
& M (2121 h —
Nanw `eesOfMenet tram bailor)
a • • 73 5-Iy C7 .
- Fl--CCE;f ct? Thep ne rase..
B. Pumping Reco
ls+f /El :c Z. DuerdMyPumped. . Iavow
0,. .1. Dete.oP.Pumpb,g ode,
3, Type:o .system: E Cesepool(s) )'SePtic Tank 0 110TanK 0 Grease Trap
0 Other.(deecdbe): �, �
4. Effluent Tee Filter present? I] Ye 0(n° If yes was It clew ied? .0 Yea ryrso
5. Condition.of System: /. .r -
5. System m\` n (Pumped By
Ands Liam Handy _ '
Slit iOe. :1/tee '
7. Lo,eon where contents were disposed: ..
Sit) c
Spholpe dMeager
9pndur.of Receiving Ptak
ar—warpre Record Pelle 1 of 1
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