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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 eromM.dev owe -