503 Pump Report 4-2020hm�s�n7
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Commonwealth of MassgchusW%
City/Town of .'c 5
Sy$tem .Puvrfpin§ R.666rd: ,
Form" 4 .
DEP has provided d is fairri for use by local Boards of MOSIM. Mer#atms mfr be used, but the
information must be eubetantially the spilus as. that MuMod hers. Belbre ung this•form, check wtih your
local Board. of HeaMh to determine ti ,e,Wn.they use. The system Pimping Bedard mtkt be.submis'ed to
the local Board of HMO or otfW approving authority within U days ftn tiro pumPbg dlde in
accordance wdh 810 CMR 15.351.
A. Facility Info.ft tion
0 out 1. system Looadon:
use addMM
h key '.
Wet aMt" -
oWrown Zip Code
5 79WOne Nwtm
B. Pumping Record
VL- J56d
1. D.de:of Pumping 2. Quantity Pumped: :
3.. Type.of syeterrr: ❑ CaPSeRao�(s). �3epUcTank ❑ TlghtTank [IOreaseTrmp
` C`�'D�')�''�b'�("P�l.l`�N i`� �I`=�s�l' `�1-Ir CIC, �I �(n•S .
❑Other. (cfw a lbe) —
4.. emuent Tea titter present't ❑ Y/.. No If yes, was It clearied? ❑ Yes idb
5. Candfion. of System:
B. system mped t3y
v*J* U=w
7. Locatlortrwhem contents weirs dlepoead:
SION'b" of Date
s ;p reof Reach" F La ty Dare
$YdXn PW V" ReCWd'PW'I of I 1
s � -.. � 08/09. '.., b '`a• ` � "k ....