11 Pump Report 4-20204.
Corrimonwealt of Mrassfichuse ft
Cityrrown of d iii
System .Purr n� R' cord
FOM 4.
DEP has provided We form for use by'locel Boa* of Health. Ober Tom may be used, but the
Information must be subdant* the Wna as that provided hens. Bellbns usingf b ibim, dm& wfth your
local Board. of Health to detarmine Uta farm.they use. The Sysbs nPumping Record mtfat be:subm"d to
the local Bond of Haaltlt or otfter spprovIng su wily w8htn 14 days from the pumping date in
accordance with 310 bMR 15.351.
A. Fs Dotty it o.ftation
1, system Location:
use �� --
Mr
WnHMYM.
cuter= do not frown State. Zip Code '
UNt to MUM
2. owner
Ad& oft
IJU�{ i TI + l".�• ���f
(N MMM)
sum
7 .
B. Pumping Record
`
A. ' D•ate.of Pumping —~- " 2. Quay* Pumped:. Soo
3., Type.af:systsm: L7 po�(sy. ,,.rte Tank ❑ -pg Tar* ❑ Orease%Trsp
❑ Other. (describe):
r— C'CI27 J; 1711 C-
4.. eluent Tea Filter present? ❑Yea , No Ifyes, was it dea*? 0Yes
5. co�nc5tlon. of System:
g, mpod By:'
vewcb Lbaw rnenuer
7. Lot lton'wherecont"Wwedlspoesd:
ftm* re of f2OMMV Famw DOB
y�pRn4.�dob 09109 npfnp '
PaAe 7 aP i
sySem Pu