100 title 5 Pumping Record, 2009 Commonwealth of Massachusetts
City/Town of
System Pumping Record
(1/4Form 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.
Important:
When Slop out
forme on the
computer.use
only the tab key
'.c move-y :
do not
use the return
Key
A. Facility Information
1. System Location:
—1 �o Fti 9L-E�
• Add eara
�OReN_CF (y 5$ O
City/Town state Zip Code
2 System Owner.
e l _ AoInc / a
Name
Address(h different eom locetlon)
City/Town
Slate Zip Code
5$ 6- 857.5
Telephone Number
B. Pumping•Record
1. Date of Pumping Date og - 2. Quantity Pumped:
3 Type of system: ❑ Cesspool(s) a-Septic Tank ❑ Tight Tank
❑ Other(describe).
4 Effluent Tee Filter present? ❑ Yes 'No If yes, was it cleaned? ❑ Ye 'J No
5 Condition of System:
/fad
Gallons
❑ Grease Trap
6 System Pumped By:
t o /a/s,E/ �9 j_god
Name Vehicle eon Number
Superior Septic Services
Company
7. Location where contents were disposed:
/ gw/ki o "r
aipnelur e of auto
�( ry
Signature of Receiving Facility
/1- -O5
Dale
51 -
Date
i5lorme doe*01/06 System Pumping Record • Pepe • of.