587 Septic Pumping Report 2015 Important:
When filling out
forms on the
computer,use
only the tab key
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Commonwealth f Ma sachuss
City/Town of /U.,0 /1tP /
'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 tc
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!
Cityfrown
2. Sa`ste
Figs; 2A tteki
Noma
& 7 COl &S i7)CIP4ui
Address Of different from location)
Citytrown
B. Pumping
1. Date of
3. Type of sy
❑ Other
4, Effluent
5. Condition
�jPC��
$ystergP,�t
Company
7. Lgcation w
g Record
3c Nr- 1 I -l5
Pumping Dale
State Zip Code
stat'//e%%��// [ of Zip ¢/
Tel•' a Number D /(
2.-Quantity Pumped'.
stem: ❑ Cesspool(s) Septic Tank
(describe):
CQ7dl�)f�TP/L+Air
Tee Filter present? ❑ Ye Nc If.yes
of System:
❑ Tight Tank
1.57:C
Gallons
❑ Grease Teap
as it cleaned? ❑ Yesr. o
mped By:
Nan
S
sl�Lll S�
herontents were dispnedi
Wheel License Number
,Sire of Hauler Date
Signature of Receiving Facillty Dale
15(orma.d0c 03(06 System Pumping Record•Page `, of 1