67 Septic Pumping Record 2016 Important
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Commonwealt of M sa ise"ttss�
City/Town ofQ LN �l
System Pumping Record -
Form 4 -
DEP has provided this forrri for use by local Boards of Health.Other form may be used,but the
information must be substantially the same as that provided here. Before using this.fom,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:
Acidness
clplrown
2. System Owner. %.5(45 Io
G7 acS) wiLSaN . 64),
$1811818BIN diemnt tom bedew)
Ctyfrnwn
3fl—a2 < ,
B. Pumping Record
elephono Number
- -1. Date.of Pumping r'Y �J i 2. Quantity y Pumped: Gam
3. Type of system: - is Cesspool(s) :Septic Tank ❑F1Tight Tank
- - C other.(describe): O` �� CroomTIOE. V e-12"4
4 Effluent Tee Filter present? ❑ Yes Jo If yes,was It cleaned?
5. Condition.of System:
❑ Grease Trap
i7-I CA4
❑ Yes2 i
6. �Saawed By:
#( ke 1i `Situ wo%:
7. Location here contents were disposed:
S
glo.m4.dov 0310e
VeNde license Number
si hatre of Healer.
Signature of ReoeMng Facility
System Pumping Vim'Paget of