56 Pumping Record liuinrnonweaim or Massachusetts
City/Town of W G 1-0,7,4n -Er) k1
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
computer,use
only the tab key Address
to move your
cursor-do not
use the return
key.
E
City/Town
2. System Owner:
K G-ouL6T
Name
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bYf i
State Zip Code
Address(if different from location)
City/Town
State 7/.7 Zip Code
elephone Num er
B. Pumping Record
ScPT9c oei
1. Date of Pumping
Date
3. Type of system: ❑ Cesspool(s)
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
•
2. Quantity Pumped:
Septic Tank
Iborj
Gallons
❑ Tight Tank ❑ Grease Trap
6
No If yes, was it cleaned? Yes ❑ No
Name
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i
Alois 51- e 1Xt
ompany
7. Location where contents were disposed:
Lisa'
Vehicle License Number
Signature of Hauler_
Signature of Receiving Facility
Date
Date
System Pumping Record•Page 1 of 1