22 Title 5 Pumping Record, 2010 Important:
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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 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
Cityffown
2 System Owner:
State Zip Code
City/Town
B. Pum i g Record
1. Date of Pumping Dale 2. Quantity Pumped: Gallons
3 Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank E Grease Trap
State Zip Code
Telephone Number
Other(describe):
4. Effluent Tee Filter present? L Yes F.N If yes,was it cleane c No
5. Condition of System:
Oo1)
6. System Pu,,��r��rped By.
�V1
Name
Company
7. Location wh e contents were disposed.
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Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record•Page 1 of I