223 Title 5 Pumping Records 2010, 2014 Important:
When filling out
forms on the
computer,use
only the tab key
to move your
use -do not
the return
key
49
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Commonweal of assachusetts
City/Town of %) Mt/0k
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:
>
ST1F ItN uit C-
State Zip Code
ViPoc- gzri,
different from oration)
City/rown
State Zip Code
Telephone Number
B Pumping Record
f4- i
1. Date of Pumping
Date
2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank C Grease Trap
L' Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? .h Yes L N
5. Condition of System:
6. System Pum
Name Vehicle License Number
Company
7 Location ere contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
iROrm4.doc•03/013 System Pumping Record•Page 1 of 1
Commonwealth gf Nassachusett
City/Town of D Grp
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 yS_r
iocat 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 Ir
accordance with 310 CMR 15.351.
A. Facility Information
When mong out System Lccatior:
'r.s or the
▪ h t▪ he tan hey Address
to move your
ourtar do not
use the return
key
Grycown
2. System Owner
S S ,- I1t6 g L= G-
State Zip Case
Namer2 3 17)0pCW,DCL gs)i
Address(if different from location)
City/Town
)0\44 INEnPTo11�
s;ep3 .3020 • fit
Telephone Number
B. Pumping Record
Date of Pumping Pate I 2 Quantity Pumped. ons
3. Type of system'. -I Cesspocis) aepticTank Tig'ni Tank E 3reaseTrap
Other(describe;_ (A
4. Effluent Tee Filter present? ] Yes o
5. Condition of System_
If yes..was it cleaned? ❑ Yes 2 So
6. Systerne}ynped ey:
reN}r etc (/ e_ toO / / VehlGe License Number
to (L �lL%n,/„��
7. Location where contents were disposed:
U? � -
29ipfeeof Hauler Dote
Signature of Receiving Facility Date
t5form4.dog.03/06 System Pumping Record •Page 1 of
SEPTIC TANK PUMP WORK ORDER
KARL'S SITE WORK
327 River Drive Hadley MA 01035 karlssitework.com 413-549-5396
Job Type:
❑Title V Job ft ❑Septic Pump
Customer Name Judy Steinberg
Address 223 Mapleridge Road Florence MA
Phone: 413-320-2368 Cell:
Billing Name:
Billing Address: same
Email:
Date Ordered: 7/25 Scheduled Pump Date: Aug 1
Date Pumped: cc- /'
We uncover no Hrs.-Li .0 +&61C(-- We backfill no Hrs.
Dump Fee. 2L O ) 51401
Electric Rod Time:
Disposal Fee
Type of Tank
❑Septic: 01000 1500 02000 ❑other
Hand Rod Time:
Pumper Truck )°2C1 hrs.
OHolding/Tight Tank: 02000 03000 ❑other
Condition of Tank when pumped:GLAC\f% '- �) C04 C.l` E*- Q -' )4n-r) G07-C3i
(,NcW. - h/l _ - F,luical
Special Instructions: pst- is unc /3 tops uncovered