218 Septic Pumping Report 2010 ,g t/t 9?1 - 6 ?V-2-
Commonweal kh of�v]as� s tts
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 submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 OMR 15.351.
A. Facility Information
Important 1. System Location:
Important:tat: out
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return
key.
4
Cityliown
2. System Owner:
m rtm (t Qc r
al coU S hill- &(JOw
Address(if d tferent from location)
State Zip Code
Cityaewn
State Zip Code
Telephone Number
B. Pumping Record A (polo 'SC 0
Date of Pumping (. lu 2 Quantity Pumped: Cations
Date 3. Type of system: U Cesspool(s) Q-Se-ptic Tank E Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
Goc'6 D 15
6. System Pumped BY:
Na RE
(6
1 l
If yes,was it cleanecin No
Company
7. Location where contents were disposed:
Ck) S
t5form4 doc•03/06
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility Date
System Pumping Record•Page I of 1