142 Pump Report 2019 • der//P- PE,lJ1i
12;, Commonwealth of Massachusetts
M iti City/Town of d/Qh;,,,..ap
w System Pumping ecord -
_1 Form4
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 ttdadorm,check with your
local Board of Health to determine the form the local Board Health other approving aauutlmrity within 14 dayuse.The System s hen the Record
date Imust be nubml![ed to
accordance with 310 CMR 15.351.
A. Facility information
•
MerrarrC0 out 1. System Location: e. .
nia:
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2 Systole Owner
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B. Pumping Record ynpit • i 500
'�'I Q c.2. Quantity Pumped: oalwv,
.1. 'Data.ofPumping bath
3, Type of system: Cesspool(s) )2-Septic Tank 0 Tight Tank ❑ Grease Trap
0 Other(describe): i- mnip f12rmGntr
4. Effluent Tee Filter present? ❑ Yes/Ho If yes,was It cleaned? .❑ Yee 'No
5. Condlffon.of System: -F
1 System Pumped By:
WIN
While license Mentor _
7. ' WhileWhile
Lo1cadloonn4where contends were deposed:
V 1 c) IT
Sider of Neuro. ._ hole
Signature of Receiving taloa Dab .
tlform.l.dore o-o-03/0e - System Pumping Rome'•Page 1 of I