272 Septic Pumping Record 2009 Important:
When filling out
forms on the
computer,use
only the lab key
to move your
cursor-do not
use the return
key.
t5form4.dac•03/06
commonwealth of Massachusetts
City/Town of
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
2. System Owner:
L &H
7e0- f`IFITHe=L0 S7
State Zip Code
Address(if different fro location)
1-10/7)
Cit !Town
B. Pumping Record
1. Date of Pumping
0 cT c/o °I
Date
State ({{{]///��/' /n/ j//(j
on2iJUmber/" c/
2. Quantity Pumped
ode
10 c -
Gallons
3. Type of system: ❑ Cesspool(s) [ eptic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
6
Nary Pr
fig is 5,7 e LOOVe.
If yes, was it cleaned? ❑'Yes ❑ No
ompany
7. Location ere contents were disposed:
INS
Vehicle License Number
Signature of Hauler_
Date
Signature of Receiving Facility
Date
System Pumping Record•Page 1 of 1
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