203 Title 5 Pumping Record 2010 455/t - o 7VZ
Commonweal °Massa9 usetts
City/Town of JV2%1 4.0z.
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.
Importan •
When filling out
forms on t e
computer,use
only the tab key
to move y or
cursor-do not
use the return
key.
A. Facility Information
1. System Location:
Address
City/Town
2. ystem Owner'
State Zlp Code
22 rn&pte RA) 3-€r RP
Address Of different from location)
City/Town
B. Pumping Record
1. Date of Pumping
State Zip Code
Telephone Number
iizkg 616
2. Quantity Pumped.
3. Type of system: D Cesspool(s) Septic Tank
❑ Tight Tank
/500
Gallons
D Grease Trap
❑ Other(describe)
4. Effluent Tee Filter present? D Yes
5. (1-6C0
Condition of System:
If yes,was it cleaned? r s ❑ No
6. System umped By:
Na e��
Company
7. Location w> re contents were disposed:
NS
Vehicle License Number
Signature of Hauler
Signature of Receiving Facility
t5form4.doc 03/06
Date
Date
System Pumping Record•Page 1 of 1