19 Pump Report 6-13-19 14 ' Commonwealth of Massischuse#s
GitylTcrl'l off.
Syeter' Pparvo.`F(adord
Farm
DEP has provided this fb m for use by local Boards of Heaft other firms may be used,but to
information must be substsritially the safne as.that provided here. reusing this•farm,check with your
local Board.of Hear to determine tha fprin.they use,The.System Pumping Record must be submitted to .
the local Board aP Health or other approving authority within 14 days from the pumping date in -
accordance whh,510 CMR 15,351.
A. Facility Inforniation
Gmporbmt r
ulhen filling out 1. System Location:
femm'on the'
computer,uae- ,
only_the tab Key Address
to moue your
amwr L do not f,l�in slates zip Cade ,
use the rstum
kw' 2. stem Owner
{:=
r
Add*a•(9 dffftrerlt from boaflon)
. Citytrown
� Ow 03, Number' ?'r
B. Pumping Record"
.•1. D,ate.pf.Pumping Dane ' Quantity Pumped. cpm
3, Type;of
.System 'cesspool(s) • 21 Tank p Tight Tank ❑ Grease Trap
El other.{descrife}: " Ca
J.
4. Effluent Tee Filter prepard? ❑ Yes.N •If yes,was it clearied? .❑ Yes NO
5. condition,of System: / +` '
Pumped By. I.
Wilde License Number r.
• r (/IJ
oil)
?. Location where contents were disposed:
Sight Of Hauler. ... Data
31
signature of Receiving FBaft Deb
i6iprm4.doca 03108
system Pumping Reaord-°Page 1 of 7