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Commonweal of Massachusetts
City/Town of fl"'y 'h
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. System Owner'
)-.10 LN
[Name
70 CouNi 6 ijWA<
Address(if different from location)
City/Town
mmP e ac
B. Pumping Record
(OG9l0
1. Date of Pumping
Date
3. Type of system: ❑ Cesspool(s)
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
i
5. ConditioJjf System:
Gnu
Stati' / - < S tr_Co9f7 t_t j
Telephone Number
1,5 b
Gallons
2. Quantity Pumped:
Septic Tank j Tight Tank ❑ Grease Trap
If yes, was it cleaned? 'Yes ❑ No
6. System Pg1ped By:
Naive_
Company
7. Location ere contents were disposed:
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility
Date
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