75 Septic System Pumping Report 2009 •
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Commonwealth of Kas achusetts
City/Town of nI JUGS 074 ) j 7 ci1U
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:
Address
City/ own
2. System Owner:
Name
cl--\GS7L F,k— UO
State Zip Code
d''re``ss(if different from location)
` Lvs/
Qtyfrown
State
3/1 Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system:
Date 2. Quantity Pumped: Gallons
❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
IocC)
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
(c-0o�
If yes, was it cleaned? Yes H No
6. System Pumped By:
Nag
97
X .20
Name; M r� I Q, Ve icle License Number
Company
7. Location where contents were disppo�sed:
P
Signature of
Date
Signature of Receiving Facility
t5form4.dac•03/06
Date
System Pumping Record•Page 1 of-I