180 Title 5 Pumping Record 2010 Important:
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only the tab key
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Commonweal ofJVlassachusetts
City/Town of 71"tIci
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
1. System Location:
Address
City/Town
2. System Owner:
R-TlL
a l P
Address(if different from location)
City/Town
State Zip Cade
State (5 O(c4
Zip Cade
efephane Number
B. Pumping Record
S&PF9 \ (U
Date
1. Date of Pumping
3. Type of system: ❑ Cesspool(s)
'] Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
2. Quantity Pumped:
iSeptic Tank ❑ Tight Tank ❑ Grease Trap
allons
If yes,was it cleaned?
Yes ❑ No
6. System Pumped By.
)
Names /t
Company
7. Location where contents were disposed.
Vehicle License Number
Signature of Hauler
Signature of Receiving Fealty
Date
Date
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