145 Septic Pumping Record 2010 Commonweal ofJViassachusetts
City/Town of I� � h
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 filli g out 1. System Location:
forms on he
computer,use
only the tab key Address
to move y ur
cursor-do not Citylrawn
use the return
key.
2. ystem Owner:
S cos)W P- 1 f
tam ,^ nf_, 1. TL% _FILM R4
Address(if different from Vocation)
State Zip Code
1 City/Town
''-� State / / f 07719
yry Telephone Number
B. Pumping Record
.31)kS4 B- t b 1.00-0
1. Date of Pumping Date � 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) _2 Septic Tank E Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present, ❑ Yes I[u No If yes,was it cleans Yes ] No
5. Cgndition of System:
6. System P umpgd By:
Name ``.Nt.?._h/
Company
7. Location w ere contents were disposed:
k S1/
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1