535 Title 5 Pumping Records 2015 Commonwealth of as scliu$efts
�u f /
City/Town of " 1�.ii'�ei
System Pumping ecord
Form 4
DEP has provided this form for use by local Boards of Heat.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:
Wnen filing out 1. System Location:
forms on the
computer.use
only the tab key Address
to move your
cursor-do not CltyROwn
use the return
key. 2. em Owner.
Lit
6 Q2ftew • t 03be-
Nam
Address(If different from location)
City/Town
F1 Croc€
B Pumping Recor
1. -Date.of Pumping
State Zip Code
• 187; s 51/ -a 8'1
'Yele one Number
te
o kJ- 2. Quantity Pumped:
1500
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ light Tank ❑ Grease Trap
❑
other(describe): — CampnarbtNT- -RS Cotr M -eft5sEV
sen?nP D, (30 rou. oFS!aubGC-
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes,�i No
C
Con on of System: y D.[JET (y1E`C�S 11260,13(h3 E'
GOOD) F•ri \ Q41-141 c>k}- ter eott2 Nctos t?F14I N S
/0 'toe — 31` 43arTom
6. S_ystempursiped By:
a S l A '•/D/k✓L^ A Vehicle License Number _•f�l/ 'Y'�C"
mpad
7, Location,jhere contents were disposed:
tSform4.doc 03/08
e-/Signature of Hauler. Date
Signature of ReceMng Fadllly Date
System Pumping Record•Page 1 of 1
Commonwealth of assAchusetts
City/Town of '0/ ,( -11°4rr
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 filling out 1. System LOtation:
forms on the
computer,use
only the tab key Address
to move your
pusor-do not
use the return
key. 2. ,arystem Own
X11 V"�IK3 4 405 e
City/Town
Address(N different from location)
Slate Zip Code
City/Town
RciiftE
B. Pumping Record
Telephone Number
150°
1. -Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? 0 Yes t o
5. CondNon of Syste
—1 1 E S, � IUiL cat[ Sr�7C d� f ( !s 1�1�f
8. rte (.7 -. : : r4S ?JrV Er-
D/k,✓Ln te Vehicle license Number Ees
mpany
7. Location contents were disposed:
wrk
lifprm4.doc 03/06
Signature of Hauler ,
Signature of ReceMng Fadlity
Date
Date
System Pumping Record•Pagel of 1