639 Title 5 Pumping Record 2010 Important:
'Ogden fill: g out
forms on the
computer,use
only the tab key
to move y ur
the N-d not
use e re urn
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Commonweal h� ofMassachusetts
City/Town of )1'I1(Cl2
System Pumping Record
Form 4
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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:
2.
Address
Address(if different from location
City/Town
1-1/409
t5form4.doc•03106
St O ry/J7de
Telephone Number
B. Pumping Record
1. Date of Pumping
Date /
3. Type of system: ❑ Cesspool(s) L�' Septic Tank
E Other(describe): /
2. Quantity Pumped:
Tight Tank
Gallons
Grease Trap
4. Effluent Tee Filter present? J Yes o If yes,was it cleaned? L' Yes No
5. Condition of System:
6. System Pumped By:
Nary t
Company
7. Location 1ere contents were disposed:
VS I
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record•Pagel of 1