242 Pump Report 2019 .
t, Commonwealth of Massachusetts
' City/Town of
D-ord +
i. siti '
System Pumping. RecoForm 4
-
DEP has provided this form for use by local Boards of Heath.Other Tohns may be used,but the
irdornaton must be substantially the spine as that provided here. Before using ttde form,check with your
local Board.of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance whit 910 CMR 15.351.
A. Facility Information
Mportmt _ e` .
wren Mhng out 1. System Location:
cams on the
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oM'te tab lacy Address . .
to move your ..
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use We Mum CM/Irwin Stats Zip Cade
2. System)Owner'
. 13-444r-S-T-Cgs 119 km;,int '- 4s-fawn
lLK] Ado (W differentfrom locam)
Ol froom .
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B. Pumping Record .
yW %i_
. in)'ila.(. 3 l q- I Soo l560
•1. 'Date.of.Pumping lots 2. Quantity Pumped: Gam
< 3, Typiof-system: - Cesepool(s) )^Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): F Co Prewar i m fuT-
4. Effluent Tee Filter present? ❑ Ye.s.,, o Wyss,wast cleaned? .❑ Yes ]No
5. 6 of System: 'r
Ctt-m N'l'Ri?VOW 1)-0 CV
8. SystemPumped By: I Stitt 1 w
tcity is '
7. radon rre contents were disposed: 4
Sgmebae Of Helier Dent
Signalise at ReceMng Fed* Da
Wpm*doc 03/06 - system Pumping Record Pegs 1 of 1