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
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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