169 Pumping Record Commonwealth of Massachusetts r�r
r _ City/Town of /'V 0 r-{2 Am a fa n
t.M." System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310-CMR 15.351,
A. Facility Information
Important
When filling out 1. System Location:
forms on the
comp:ter,use
onlp the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
5 0 e 2 %RS
Name
160/ C 1'LDr`N &L kl
Address(if different from location)
FLoaeNce
City/Town State Zip Code
Telephone Number
B. Pumping Record p
1. Date of Pumping Sa?PT a`5o 2. Quantity Pumped: ` S
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g E Grease Trap
❑ Other (describe): � ' _—
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? 2 Yes ❑ No
5. Condition of System:
,C r`-wet L-v3'DG00 , 1\Z0,,u1v SC UL YZ> ,
6. S_-___,:.. . :;r
KM
eNa e
'9/S �` e /, y��, Vehicle License Number
ompany �'�t���
7. Location) 1ere contents were disposed:
N S tJ
Signature of Hauler_ Date
Signature of Receiving Facility Date
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