152 System Pumping Record, 2009 f
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Commonwealth of Massachusetts
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:
_c>Iny
Addy* '
�� 1Z 1 et7z C a
stets LP Cods
Gay/Town
2. System Owner; CCit\1
Name —t\�-°�i,k-!,�j
Address Of different from locedon)
City/Town
State
Zip Code
41f3 —Sg11— 6: 233
Telephone Number
B. Pumping Record
1 Date of Pumping
S-f4 1 2. Quantity Pumped:
Septic Tank ❑ Tight Tank
Date
3 Type of system: ❑ Cesspoot(s)
❑ Other (describe). ,.
Lc GCS
Gallons
❑ Grease Trap
4 Effluent Tee Filter present? ❑ Yes l>r No If yes, was it cleaned? ❑ Yes ZNo
•
5 Condition of System. p
6. System Pumped By.
Nit C7 2— C lS �"� —( . t
Name Vehicle License Number
Superior Septic Services LLX-
Blormldon 03/06
Company
7. Location where contents were disposed:
? lvv� ln{l /t�C2_ �czti -tf,
v c
V?t4
Signature el Hauler Data
Signature al Receiving Facility 1. Date
Sr-1? G . -