219 Septic Pumping Reports Important:
When filling
out forms on
the computer,
use only the
tab key to
move your
cursor-do
not use the
return key
IWP
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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 CMR 15.351.
A. Facility Information
1. System Location:
Address
NORTHAMPTON /HATFIELD LINE MASS.
City/Town State
2- System Owner:
JON RENNAU
Name
01060
Zip Code
Address(if different from location)
State
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping — JUNE 15, 2015 2. Quantity Pumped: 1500
Date Gallons
3. Component: ❑ Cesspool(s) ® 0 Tank ❑ Tight Tank ❑ Grease Trap
❑ Other WE HAD TO DIG THE COVER OUT
(describe):
4. Effluent Tee Filter present? 11 Yes ® No If yes, was it cleaned? ❑ Yes ® No
5. Observed condition of component pumped:
PUMP CHAMBER ONSITE
6. System Pumped By:
LUIS
Name
CLEAN SEPTICS INC
Company
7. Location where contents were disposed:
BONDI'S ISLAND INDIAN ORCHARD
ORANGE/SILVER MAC
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doe-11/12 System Pumping Record•Page 1 of 1
Important:
When Niino out
forms on the
computer.use
only the tab key
Ocursor a -do not
use the return
key
ROW
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, chock 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
t. System Location
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Name
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Address(if Mariam'from location)
City/Town
State Zip Cede
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Telephone Numbet
B. Pumping Record
1 Date of Pumping
G (6 2. Quantity Pumped.
On
Gallons
3 Type of system: ❑ Cesspool(s) *Septic Tank ❑ Tight Tank O Grease Trap
❑ Other(describe).
4 Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes/t3 No
5. Condition of System.
6. System Pumped By.
,a' r%' Sir c7Q V 7
Name Vehicle license Number
Superior Septic Services
Company
7. Location where contents were dispo
Signature of Hauler
Signature of Receiving Facility
Data
Date
Gil%070
!aroma doe-03/06 System Pumping Record•Pegs : of I