47 Pump Report 10-2020Commonwealth of�Massischuse Es
CityFrown
System.Pttm'ping Record.
Form 4
DEP has provided this form for use by local Boards of Health. 011ier folme' may be used, but the
Information must be substarttialy the smote asthat provided hens. Belt using thia•form, check with your
local Board. of HeaM to determine the form.they use, The.Systam Pumping Record must be submitted to .
the local Board Health or other approving authority within 14 days fiom the pumping date lit
accordartoo with 310 CMR 15.351.
A. Facility Inforn atlon
' Location:
OM a
'ier
1. System
n —at the'
canputer, uee
0*Its tett Way
Address
mowydm
f wwr do not
use the retum
gty/Tawn state zip Code '
/
2. System Owner. -
Addrgsa'(rdffbFwtfrom bcW")
Chyrrown Stere ZIP Code .
_
�'�C�d\1LL - - Nwaw
B.'Pumping Record
'
A. D•ste.of.Pumpingoats -r 51U.y Pumped .. GOORS
3.: Type:ofsystem:. ' Ifl Cesspools)"-S`opticTank ❑ tight Tank ❑ Grease Trap
❑ Other. (describe):
4. • EtHuerd Tee Filter preserV 0 Yes .y o If yes, was it dearioV .❑ Ye QQ 6
5.' ConMon. of System:
6, system Pumped By,.,
7. Location whomcontents were disposed: .
S 9
ftht;6"of Hader. ... Date
%neM s ar ReoWM FadlKy Date
OOM*daa e8/ae - SYebm Pumptrp Reww.- Pae 1 of 1