428 Septic Pumping Reports Commonwealtf,hh,, of_JV]assachusetts
City/Town of/0 n171 /17
System Pumping Record
Form 4
6?i0/J7 a /V .1-
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 City'Town
key.
15form4.doc•03/06
2. 5 stem Owner:
AF FMS/
I C!-1037-r'ltR'ELD g
Address(if different from location)
State Zip Code
City/Town
B. Pumping Record
p ���
1. Date of Pumping U' 9I O
fT / f7)
lephone ber
2. Quantity Pumped:
Date Ged
allons
3. Type of system: n Cesspool(s) Septic Tank n Tight Tank ❑ Grease Trap
Otber(describe):
4 Effluent Tee Filter present? r' Ye If yes,was it cleaned?„... Yes E No
5. Condition of System
6. Sy Pumped By.
Naststeee b
Company
7. O°cation here contents were disposed:
/I"t1 SI/,f)
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facl @Y Date
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of /1K0 K— i, ,n,a Y
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but he
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.
City/Town State Zip Code
2. S stem Owner:
L
FO-11212j S
QkL ST�`2Ff� Eto 6ZJ
Address(if different from location)
City/Town
State III 3 15 0 % ' �( ride
Telephone Number
B. Pumping Record
1. Date of Pumping • 1 6 0 5
Date
2. Quantity Pumped:
100
Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
(v-COP
If yes, was it cleaned?
❑ No
Na e
is 5r9e LLZt
ompany
7. Location were contents were disposed:
,I�v` S
Vehicle License Number
Signature of Hauler_ Date
Signature of Receiving Facility Dale
t5farm4.doc•03/06
System Pumping Record •Page 1 of 1