964 Pump Report 7-3-19 Commonwcialth of Massachuseft
City/Town of '
System . ��'g. �Word
FoM 4.
DEP has provided this forrri for use bylocal Boards of Health.Otber may be used,but the
Information mint be substantially the sjsfne as.Out providpd here.Before using this•farm,check with your
local Board.of Heart to determine the lbfm.they use.The•a&y.dem Plamping Record must be submitted to .
the local Board"of Health or oder approving authority within 14 days(from the pumping date In
accordance with 810 CMR 15.351.
A. Facility Inforniation
Important System Stem Location
M hen-imng-out —
forms on the'
computer,use
only ttas tab key Address .
to mover your
u the-da not di o Stela 23P Code
1698 M UITI
key.
2. System Owner:
)Varma. 9� R6 s'c&` �
Ad&OS Of differert ftm IooRon)
Wrown Side zip Code
o
-U V��J'� ��'" T ,ion Numbe,
` S.- Pumping Record ( r
.•1. Date.of PumpingData 2. Quantity Pumped: . GW ons
- �.. 3,. Type:of-system: P1 -Cesspool(s) Sq tic Tank n i'fight Tanit 0 Grease Trap
❑ other•(describe):
4. Effluent Tee Filter present? ❑ Yes N6 if yes,enras;It cieani4 .❑ Yes o
5. Condition.of System: -•+` '
16
6. ' System Primped By:`
VMS Verde Ucense Number
7. Location where conteft were dlspmed;
41,
Sigtift"of Hauler. ... 4 Da
Signature of Receiving Facft Data. I
fforrM.docp OWS System Pumping Record.-Page 1 of t