39 Septic Pumping Record 2009 we
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Commonwealth of Massachusetts
City/Town of t /Jh4 444-in
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
CityRown
2. System pwn„ n 1/
State Zip Code
f q coo riiTJ4 Wo-u\
Address(if different from location)
City/Town
Flak CAN C
B. Pumping Record
Ocr30c 1
Sta/
Telephone Number
217/�/ Lip Code
1
mo
. Date of Pumping Date 2. Quantity Pumped: IS
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes, No If yes,was it cleaned? 7 es ❑ No
5. Condition of System:
Ci,-O«n
6. Syst m umped By:
7. Location w re contents were disposed:
y V S
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility
Date
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