600 Septic Pumping Record 2016 Important
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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 thisforn,check with your
local Board.of Health to determine the fonn 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
Clty?own
2 91Astern Owner.
µa Co G-GS wr��
b00 IANDEN \ kp
Slate 9p Code
Address grditrerent from location)
City/Town
EIS/ 1�
B. Pumping Record
4. -Date.of Pumping
0_ 19 Ice
State Zip Code
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
5. Condition of System:
No If yes,was it cleaned? ❑ Yes
6. System Pumped By:
SUUUC1uU((l13
� 'Si �
7. I,pcgtlon yihrntente were disposed:
Signature of Hauler ,
Signature of Receiving Fadlity
Iaonn4.doc•03/06
Vehlde License Number
Date
Data
System Pumping Record Page 1 of 1