23 Pump Report 202114 Commonwealth of Mess; husefis "
city/Town ofi�
Sy$irem .Ptooint ftec rd
Form' 4
c DEP has providedthls tori for use b9 local Boards of Heaft. Ottley` fohna may be used, but the
irdbrmation must be aubstantlalty the sane as. That provided here. Balore using thla•form, check with your
local Board. of Health to determine to form.they use. The ygem Pumping Record must be submitted to .
k the local BoardL of Health or offW approving authority within 14 days ttom the pumping date In -
1 accordance wfth 810 CMR 15.351.
' A. Facility Info. matiori
VA*n ON ,«,t 1 system Location:
4j L_n
60ihpuw, use
l .. o* to ab key Address
m moue your.
o wr-do not awn SEeta ztp Code .
we the return .
ap cotle' '
S. Pumping Record
\
1.. '
[1ete.of PumpingDift,2. Quanggr Pumped:
'
3..
Type:ofsys[em: ❑'Cesspool(a) '�^Septla7ank" ❑ fight7ank
❑ Grams Trap
'
pother (deecNbe): -troy.- lT n F a i WLLI'(J ]� P l
4. ,
Effluent 7ee'Filter present? ❑ Yea No If yes, was itcleaned?
•❑ Yes ' No
5.
C.ondition.of System:
(� L,
0 C--l�ss-
- r�M
6.
��mped I3yt '
_ ,r VeMtle iloeree Wanher
7•
Location where contents Were d OOOsW.
��
of Hauler . ... Date
Sten—m of Rewtft Fa ft Date
iabmi4.cloa 08/00
8yatarn Pwnpft Roc*.- Pe®®1 of