104 Pump Report 2019 del
Commonwealth of9Massachuse�,ts
Gitjr/'Torn of ~-C -
•
System •Pius n Ocard...
Y g.
Fortrk 4.
DEP has pad We form for use by•locsi Boards of Heath.Cftber ftftmay be used,but the
Information iimi be substantially the seine as.the#provided here. Before using this•fotm,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 Healthor offier approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
i
A. Fscift Inforrriatlon
When i9fing out 1. •System Location:
mans on the' . . I .'
computer,use
only the tab key Address .
to move your
cursor-do not !Town State Zip Code
use t o few J
kW. 2. System charier t r.
Name
cWIr?Wn Owe
• ��b�„1 dot E'"'r,��� Telepfwne Ntamber
B: Pumping Record . .
A. D•aft.of Pumping Datta t � �. ;.�. QuanMy pumped; �
3,• Type-of Iysfem: [Q 'Cesspool(s) Tank* ❑ Tight Tank ❑ Grease Trap
pother.(describe):
4.. Effluent Tete Fllter present? ❑ Yes�o If yes,was it cleaned? .❑ Yes o
5. 'Conditiao .of System:
6. " Systim Pumped By:'
l aNde Uca m Number
1.
7. Location-where conta tai were dlsposed: ,
mer: ... Date
.Wnaturi of ReoeW"FROMy Date
/ Oorm4AW OSM i system Pumping Record.Page i of i