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25 Pump Report 11-18-19 s y nmr6alth-of'Massschusaft ohuse city/Town bf Sy$ ®m .Purr n' t�card _ FoM4. . DEP has provided this form for use by'kxmd Boards of Health.other"may be used,but the kftma w mush bg subs> ms*the aWe sa ttmt praikW here.Babe wft'ft.fiprm,dw&with your local Board of HeaMh to ddwnlne tie lorm.they use.The&pbem Pumping Record m be.subml ted 40 the local Board of Health or OJW Mrtiirin8 suihoft within 14 days firm the pumping date In accordance with 310 CMR 13.351. A. Facility iitforMation' ' vj=iftv out i�•on the.' . WMp" ,use W Move YOM _OW=do not CWrMn Zip Code Un the W&M k+�r• 2. o-wherrM ��C� PAdMso'(g Mhnwt IMM McId") Cur/rown sue ZIp Code• ,w B: Pumping Record . A. •Dab.-of Pumping Dila ,2. Q__"_9 Pumped. . ' 3' Type;all:®ystern: Q Qegspool(a,. '' 0.4wank Q 17grtTank la Car Trap 4. Eluent Teo FBterpressnCTes.0 No if yes,was It dearies!? _ yes i]'No 5. Q`annditlon.of Sydon: roped W. ° Ag Tk VaNde LIOMM NvTiber • 7. L ere corderibe was wed: Al - ir I Data e of Rea aQ Fa ft Dab