357 Title 5 Pumping Record 2010 011X7 D %yam
Commonwea o asS t huts
City/Town of a -f e
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
Important:
'Men filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return
key.
1
Ant
City/Town
2. S stem Owner:
11 rifkr
S7 i , Fo-armS 021,
Address(if differs t from location)
State Zip Code
City/Town
State Zip Code
Telephone Number
B. Pumping Record
)(w5
1. Date of Pumping
Date
2. Quantity Pumped.
X000
Gallons
3. Type of system: ❑ Cesspool(s) is Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? Yes ❑ No
5. Condition of System:
6-60P
6. Sy t5 em Pyyrtypgd By:
N Z 6 Vehicle License Number
C mpany
T Locf�t et w contents were disposed'.
t5form4.do •03/06
Signature of Hauler
Date
Signature of Receiving Facility
Date
System Pumping Record.Page 1 of 1