597 Title 5 Pumping Record 2009 Important:
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Commonwealth of Massachusetts
City/Town of fV G A-(2f4').n -Ed v1
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
1. System Location:
Address
City/Town
State Zip Code
2. System Owner:
Ck l g`k
Name
5c7 N, Pnog
Address(if different from location)
City/Town
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Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑ Cesspool(s)
❑ Other(describe):
4. Effluent Tee Filter present?
5. Condition of System:
Craop
Oct Clod
Date
2. Quantity Pumped:
❑' Septic Tank
1500
Gallons
❑ Tight Tank ❑ Grease Trap
If yes, was it cleaned? ❑'Yes ❑ No
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7. Location where contents were disposed:
Vehicle License Number
Signature of Hauler_
Signature of Receiving Facility
Date
Date
System Pumping Record•Page 1 of 1