865 Pump Report 2019 ta, Commonwealth of Massachusetts
w f Cityrrown of n -F ' -
M system Pumping Recor
Form 4
DEP has provided thie Toni for use by local Boards of Health.Other forms may be used,but the
Information must be substantially the septa as that provided here. Before using this tom,check with your
local Board of Health to determine the form they The
ysemPumping
RMst be submitted to
the Wal Board of Health or other approvingetle.within Tram the date In
accordance with 910 CMR 15.351.
:1
A. Facility Information ,7 -
m,orantomen anus out 1. system Locstlon:
Pone on me
ampkMr,use
ody the tab Icer Address .
to move your Stabs7�p Coon .
°nor-dond *frown
use the Rd=
bn -
-
- 2. Syster9 owner:
O T 63t1i-PR
Nana-6 6g Glc=simPTory Pp
'Wall Address Address'(I different from ballon)
V
/L/GB' a,o'de.
y-LaR&NCe Te1° IO °""�°
B. Pumping Record
. . 4. "Date.of Pumping t'jk a-19` ' 2. Quantity Pumped: i Odom
A6°
a Typeof system: ti Cesspool(s) �Septic Tank ❑ TlghtTank 0 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes . No If yes,was it cleaned? .❑ Yes Jd-No
5. Condition.of System: -�
Ci()CIP
8. System Pumped By:
EU°G�C Slit Wild . vetid. , eN.�e
7. Location where contents were disposed: +-
U-s re-
Sight/tura ofHader. - Data
ire of ReceMg Fad* D�
System Pumping Record•Page 1 of l
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