96 Septic Pumping Report 2015 him 171H1- /7 `1(2i
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 submittec 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:
ferns an the
compuxr, use
only the tab key
to move your
cursor do not
use Fhe return
Address'
City/Town
2. System Owner.
J°J< C FFFC
State
Zip Code
Ime-,f
` Areemwo
Address(If different from Iocatlon)
Cityrrown
State
Zip Code
Telephone Number
B. Pumping Record
6 15
1. Date of Pumping
3. Type of system:
2. Quantity Pumped:
'Ogre Gallons
❑ Cesspoc,l(s) _'Septic Tank ❑ Tight Tank ❑ Grease Trap _
cams 11TYYl :nci
❑ Other(describe):
4. Effluent Tee Filter present Yes No
Condition of System:
5. CoeP
6. System
ed By:
If yes, was it cieaned?tes,❑ No
Na
S ht.
Company
7. ovation where con ---ts were di posed:
Vehicle License Number
Signature of Haler/
' nature of Receiving Facility
Date
Date
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