367 Title 5 Pumping record, 2010 ,a ?IX 67V2
Commonwealth of] 1asssaac s tts
City/Town of/Vj) i n
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:
when
filing out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return
key.
City Town
2 Syste Owner
7 A , /779-Rrn5 !1P,
State Zip Code
Address(if different from location)
City/Town
FLORETNCe-
B. Pumping Record 6 ii)
/550s' -�b� e
fe ephone Number
1. Date of Pumping Date 2. Quantity Pumped: Gallons G
3. Type of system: P. Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? J Yes No
5. Condition of System:
6. S(@ei Pimped By,
Name
If yes, was it clearjeorlifCs ❑ No
Company
7. Location wh contents were disposed:
uv r
5form4.dec e3106
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record-Pagel of 1