108 Septic Pumping Report 2009 Commonwealth of Massacr u
'
City/Town of ivaI �
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 ye._r
local Board of Healthito determine the form they use. The System Pumping.Recora must be submine_ to
the local Board of Health or other approving authority within 14 days from the pumping date to
accordance with 310 CMR 15.351.
A. Facility Information
Irnppna nt'.
Wnen filling out 1. System Location:
forms on the "
ompu er.use
only the tab key Address'.
to move your
cursor do not City/Town State Zip Code
use the return
2 Sy tem wner
F y� V4
'Names c_38 !
Address (if different from location)
City/Town
Uctt•I1�Rt\PToN
B. Pumping Record
,'U NNSIS
Telephone Number
p"ooe
2. Quantity Pumped': Goo
1. Date of Pumping Cate Y Gallons
3. Type of system'. ❑ Cesspool(s) E.Septic Tank C Tight Tank ❑ Grease Trap
❑ Other (describe)', ,9,—copy y'E N( OLD , PE-
4. Effluent Tee Filter present? j/]'Yes ❑ No
5. Condition of System:
6. Sys rn Mped By'.
hie
If yes, was it cleaned? ❑ Ye�s,.7 No
t
°(thr-IIS FLe
Company
7. Location why contents were di •over:
15form4.coc• 03/06
Vehicle License Number
Signature of Hauler
Signature of Receiving Facility
Date
Date
System Pumping Record •Pace t of '.