17 Title 5 Pumping record 2009 Important:
When filling out
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computer,use
onb;the tab key
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Commonwealth of Massachusetts
City/Town of WO /—(27,9 -(--r) )---f
System Pumping Record
Form 4
/Thie h n °/ `M10/'
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. S stemrOwner:
I(2u,u G lz
State Zip Code
Name
17 JU• FiJUT1S j2))
Liddress Of different from location)
City/Town
Teephone umber CJ
Zip Code
B. Pumping Record
1. Date of Pumping
?Ti X ( 09
2. Quantity Pumped:
Date
1600
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tank Tight g ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
C
If yes, was it cleaned? Yes ❑ No
6. System_. ped
Na e
dg i s S,7 e
ompany
7. Location where contents were disposed:
l
i1 is
Vehicle License Number
Signature of Hauler
Signature of Receiving Facility
Date
Date
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