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FORM 4 - SYSTEM PUMPLNG RECORD
Commonwealth of Massachusetts
-�,lDvve� , Massachusetts
System Pumping Record
System ocation
K vL�C
73y w s �-
II
Tape:
Emergency ❑
Routine
Cesspool: No
❑ Yes ❑
Sc tic Tank: No ❑
P
Yes /r—'
Date of Pumping:
L pl o!
Quantify Pumped: 1���
_ gallons
S\ stem Pumped by (Company): -1 --91 Permit
Permit
Contents transferred to:
Contents disposed at:
�cjLI/ft -fykC-I-
D `�e-�1' �� Pumper Signature
Condition of systerT other comments:
iiDEP APPROVED FORA - 1:/07195