595 Septic Pumping Report 2011 Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
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key.
fan
Commonwealth, ofjVlassachusetts
City/Town of 4/214011
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
City/Town
State Zip Code
2. Syytem Owneby Mp z1 ( 6R
(l.
�/4 YTT//C U D2CPav RPJ ,
Address(if different from location)
er\�-•(/Cii�ty/Too/wn ,- t Code
Pumping Record
i5 ‘ri i
1. Date of Pumping oe`Q 2. Quantity Pumped:
Gallons
Tale e Number
3. Type of system: ❑ Cesspool(s) Y Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? E Yes No If yes, was it cleanedyYes D No
5. Condition f System:
di
6. Systerp�p mped By
Name
�
Company
7. Inter re contents were disposed'.
S3
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility
Date
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