600 System Pumpig Record 2010 1 0 ?V;
Commonweal ofJVJassachusetts
City/Town of JV� n ivekv7
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 filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
w
sor-do not
City/Town
use the return
key. 2 stem Owner:
CoGSW-
State Zip Code
�N�v J/3yD>;N ;k(se gin,
Address Of different from location)
City/Town
ectei
B. Pumping Record
1. Date of Pumping
!-�fi//t@%3 :Stf Cr
Telephone Number
Code
Date
2. Quantity Pumped:
( Oeo
Gallons
3. Type of system: D Cesspool(s) 'r�-Septic Tank ❑ Tight Tank D Grease Trap
D Other(describe):
4. Effluent Tee Filter present? D Yes [�NO If yes it cleaned? rPrICE No
5. Condition of System:
C`/r�
6. System Pumped By:
Name*
Company
7. Location where contents were disposed:
U l S
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06
System Pumping Record Page 1 of 1