289 Septic Pumping Record 2010 ,S Hf / C 7V
Commonweal of assachusetts
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
Important:
When flii g out 1. System Location:
forms on he
computer,use
only the t b key Address
to move y ur
cursor-do not
us the return
key.
City/Town
2. System Owner:
` gar kyo,\J
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State Zip Code
Address(if different from location)
City/Town
B. Pumping Record
Z - •9 /&
Date
1. Date of Pumping
1113 5 ? 7-Oa 9g7 G
Telephone Number
2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes gi No If yes,was it cleaned? Yes [ No
5. Condition of System:
?C-) I
6. S\stem Piped By:
Nyme f—
Comipany
7. Location where contents were disposed:
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Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
t5iorm4.doc-03/06
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