421 Pump Report 2019 14 . Commonwealth of Massachusetts •
' V City/Town of • _ _
System Pumping Record -
1
t Form 4 -
PEP has provided this gam for use by local Boards of Health.Other forme may be used,but the
IMortnetlon must be substantially the sane as that provided hero.Before using thlaforn,chedc with yota
local Beard of Health to determine the form they we.The System Pimping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date In -
• accordance with 310 CMR 16.351. ,
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A. Facility information ,
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unporQr 1 System Location: ,..t
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B. Pumping Record
• . _1. 'llate.ofPumping Vet : 2. Ouartlly Ptsnpsrl: . ceum
3. TYpe:ofsystem: - III Cesspool(s) 0 Septic Tank - Tight-tank flerease Trap
. - ❑ Other'.(describe): y
4. Effluent Tee Filter present? 0 Yes4o If yes,waelcdeened? .❑ Ye,,i2'Na
5. Condition.of System: f -
6. System Pumped By:
5\U (cCJ1 Nettle DowseNumber -
pw Slit Welk
7. L��oa``stlon where contents were msPared: a. .
UV 11'
Slphaaae of Heiler. .. Dee Signalize of orRecehNg Fetalg' DW —
Bytom Romping Record-•Peas 1 or 1
taprtM.doc Dema Romping