124 Septic Pumping Records Commonwealth of Mas achuse_
,
City/Town of U J
'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 submne lc
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 rnimg out - 1, System Location:
forms on the "
computer.use
only lne lab key Address,
.
to move your
cursor.do not
use the return
key.
rano
cnyrrown
stem Ow act 02 r
State Zip Code
a u CIA F; EU) VP
Address Of different from location)
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C tymawn
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B. Pumping Record
1, Date of Pumping Matt
Date
773- (
Telephone Number
2. Quantity Pumped.
ao�
Gallons
3. Type of system; ❑ Cesrspool(s) `Septic Tank ❑ Tight Tank ❑ Grease Trap
[� Other(de \
scribe): N C I !t ti'4
4. Effluent Tee Filter present? ❑ Yes No If yes., was it cleaned? i] Ye
5. Condition of System:
6. Smur,�ped By:
Naps , tt
contents were dispoved:
Company
7. Location wherg
\\\ ,s
sir Hauler
t51orm4.doc•03/06
Vehicle ucense Number
Date
Signature of Receiving Feclllly Date
System Pumping Record 'Page 1 of 1
Important:
When Nang out
forms on the
computer.use
only the tab key
a cursor ova do not
Use the return
key.
Commonwealth of Massachusetts
City/Town of
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
1. System Location
24 C 4essregfl t o RD
• A its
Lass F� tie - -
City/Town State t. Zip Cede
2 System Owner
-rwtm£ S P . /LC
Name
Address(if different from rotation)
CMRown
Stale Zip Code
5 5 2- 0 3__4.1 TeNphone Number
B. Pumping Record
1 Dale of Pumping one - as 12. Quantity Pumped
3 Type of system.
❑ Cesspool(s) Septic Tank
❑ Other (describe).
4 Effluent Tee Filter present? ❑ Yes it No
5 Condition of System.
6 System Pumped By
)dame doe 03i06
❑ Tight Tank
LSoo
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes An No
HIKE 6/00-0•15KL N 80407
Vehicle License Number
Name
Superior Septic Services
Company
7 Location where contents were disposed:
£r 1 i
oft
Signature of Mau
Signature of Receiving Fa
5'-! 9OS
Date
:: -0 r
Date
�cr
System Pumping Record• page I of