120 Septic Pumping Report 2015 •
Commonwealth of Massachusetts
City/Town of / D ii 6.tr` -h2rr
System Pumpi�g Record
Form 4
CEP 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 ycu
local Board of Health'to determine the form they use. The System Pumping.Record must be suom:neo �c
the local Board of Health or other approving authority within 14 days from he pumping date I'c
accordance with 310 CMR 15.351.
A. Facility Information
Important)
s,.r,e;.,=,iirs out 1. System Location:
forms on the ' `
computer.use
only the tab Key Address''.
to move your
-cursor-do not City/Town Stale Zip Code
use the return
key. 2. System Owner:
Name «C cV 7lrCapctu R® •
i
Address(if different from location)
City/Town W� State c�z/ ` 4 Zip Code
��11 r�aeU Telephone Number
. B. Pumping Record
1. Date of Pumping Tkil\ L V3
Dale 2. Quantity Pumped. IS-0
Gallons
3 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank r l Grease Trap
carn
❑ Other (describe): fnilflT'e L oLa 1 46
Effluent Tee Filter present Yes E No
5. Condition of System'.
6. Sy stem Rt -tped By,
IS Se. :,ffL
Company
7, Location where conje(tts were di po vil:
`
Na
f yes, was it cleanedh es, No
Vehicle License Number
Signature of er
Signature of Receiving Facility
;5form4-dom 03/06
Date
Date
System Pumping Record •Page 1 of