46 Title 5 Pumping Record, 2015 Important:
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forms on the
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only the tab key
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cursor-do not
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Commonwealth of Massachusetts
City/Town of g'a
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 some 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
Clty/rown
State
Zip Code
Addreaa-(d different from location)
Clty/rown
rikitLENC
B. Pumping Record
fir? ,f t O 4.33-
A. -Date.of Pumping 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Gre Trap
15r:G
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
6. \..) Ped By:
If yes,was it cleaned? ❑ Yes
Company
7. pLoccatico''nn re contents were disposed:
OV c?
Vehicle License Number
St y wOfAn -
INOmm.doc•03/06
Signature of Hauler
Signature of Receiving Facility
Date
Date
System Pumping Record•Page 1 of 1