29 Pump Report 10-28-19 " Comm.dnvveatth of Mssaohus s
Ci own ofl- �����/V'i�
System -P4MI no,-'ROcord
Form,4 . .
DEP has provided dims form for use by•kxat Boards of Health.Other fohns'may be used,but the
informadori must be;substantially the same asthat provided here.Before using this•form,check with your
local Board.of Health to determine the form.they use.The Sy$etn Pumping Retard mm—be;submttted to
the local Board of Health or oder approving authority within 14 days from the pumping date in
accordance with 810 CMR 15.551.
A. Facility h1forniation
import ,. ! _ •. ,
mem iming out 1. 'System Locatlon:
inrms-on the
WMPuter,use
o*the tab key address .
to move your.
cursor=do not
use the return° St* Zip Cade
key. 2. System Owner
C_ yds ism r'
9- '. • r
A,ddMw,(gdfflbmrtftnm low&T)
Q�
41- 3 �58(-1 �Cj�
u v !
TWWNM NMbe'
S. Pumping Record
• 4. Date Iof,Pumpfmg � i �� 2 Quar*Pumped:
Dais Gdons
z - 3. Type.of system. ❑ Desspool(s). eptic Tank ❑ Tight Tank ❑ c3rease Trap
❑ Other.(de
.Iscribe):
I
4. E•flluwd Teo Fitter present? ❑ Yes, o if yes,was it ciearied? o
• 5. Condition.of System:
6. . mOW '
yefre Uosnse Number
7, L on.where contents were disposed: ,r '
StgnMM of er
ucignatum of ReaeMv Fad* ;
Date
1 'm4.doo-08109 SYMM PWPft>tq Records Page f of I
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