721 Pump Record 3-2020Commdnw6alth of MassachusWs
City/Town of
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DEP has provided this form for use by'local Boards of Hsaihi. 00* " may. be used, but the
Inibrmaijori must be substantially to one as that provided here. Before tvft thle-fonn, chack with your
iocai Board. of Health to determine the trm.they use. The System PumpkV Record mast be sub to
the local Board of Heam or other approving autho.* within 14 days from the pumping date In
acoordancewith MOCMR 16-351.
A. Facility Information
Important ut syidarn Location:
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GOMPUW, use
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to move your,
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B. pumping Record
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A. Qate-of.Punips am QuW* Pum 'GaIMS
3, Type.Of- . system: ❑ 'C"POOKS) "�--qvftTank El Tight Tank El Grease Trap
Fj other. (describe):
4.. Effluent Teo Fitter present? Ej Yes No If Yes, was it cleaned? 0 YesFIG
5. Cmdidon. of System-
Ve*Ie Umm Number
7, Location where corftlW WGIS disposed:
C
ftneturs of ReOeMM fROM
Vonn4AOM 0"
Date
Don
&JMM PWPM Record' Paget Of I
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