39 pumping 2010 CommonweajJ,h� of_Massachusetts
City/Town of/V� e /ch
=y System Pumping Record
. ;'v:. =is 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.
„") '7/ Uj7/Gi.
iyA
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer.use
only the tab key Address
to move your
cursor-do not
Coy/Town
use the return
key.
6
fierA
2 System Owner
/e Geu"n 'q/
J 02,,
Address(if different from location)
State Zip Code
City/Town
216 -215
-telephone Number
Zip Code
B. Pumping Reseal
° -
�af
1. Date of Pumping Date �� sUZ
2. Quantity Pumped: G
Gallons
3. Type of system. ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Grease Trap
E Other(describe):
4. Effluent Tee Filter present? ❑ Yes LJ No If yes, was it cleaned?
5. Condition of System:
cock)
6. S stem umped By.
N men
C moony
7. ocaton where contents were disposed:
s�
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
t5formu doo-03/06 System Pumping Record•Page 1 of 1