330 Septic Pumping Record 2010 B H�' �//i7 6
Commonweafl � of] 1assachusetts
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 CMR 15.351.
A. Facility Information
Important:
When fillin out 1 System Location:
forms on t e
computer, se
only the to key Address
to move y ur
cur or-do not CityrTown
use the return
key.
2. System Owner'.
. T�s C:12
crA �30 Pa;/ �� coviU?s
Address(if different from location)
Aim,7tt7
=t cuu rsh
State Zip Code
City/Town
Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dam 361 2. Quantity Pumped: 006 Gallons
3. Type of system: 0 Cesspool(s) Septic Tank E Tight Tank 0 Grease Trap
E Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes,was it cleaned? Yes fl No
5. Condition System.
on of Syste
6. S sy terruPumped By:
Na me )
e J
Company
7. Location w re contents were disposed:
S ,
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
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