889 Pumping report 2015 •
■
Cornmonwealth Ma
m sachusett
City/Town of Iy o /.1)k,f 1' C
° n,
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 yocr
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
Important'.
Wnen(fling out 1. System Location:
forms on the
computer use
nary Ina lab key Address
move your
-
cursor-do nor
City/Town Stale Zip Code
cse tae return
hey 2 System Owner.
1)e1 �-�14lz SUt v
m k`j Coll 1� h�uuu
Address of different from location)
City/Town
i\ jj IV raf iG 1
• . B. Pumping Record
y
1. Date of Pumping " Dabs'\ 2. Quantity Pumped.
State
Zip Code
Telephone Number
Gallons
3 Type of system: C Cesspool(s) _'Septic Tank ❑ Tight Tank ❑ Grease Trap
vJc t \ICK r 3�-y�S,
Other(describe):
4. Effluent Tee Filter present? C Yes ;XNo If yes, was it cleaned? ❑ Yey,J No
Condition of System',
CSC*
6. System Pumped By:
Na4 'S LS C
Company
7. Location where contents were d
1, i
3- 'S 2
Vehicle License Number
Signature of Hauler
pate
Signature of Receiving Facility pate
heforma.dco 03/06
System Pumping Recoro Page `a