VA Site Title 5 Pumping Records 2009, 2015 Commonwealth of Massachusetts
z City/Town of Q%{hn p ' �o/4
System PumpingRecord
Form 4
CEP 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 yo.
local Board of Health to determine the form they use.The System Pumping Record must be submitted
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
moo nano
When filling out
forms On the
corn pore r.use
oMy the tab key
to move your
cursor.do not
e vie return
4i
A. Facility Information
1. System Location:
Address
CityROWn
2. System Owner'. ^^( C`M—CR
N = c
A- 121 t
prhi
Address(if different from location)
Slate Zip Code
Caygown
S
B, Pumping Record 5 moo
1. Date of Pumping �� 2. Quantity Pumped'.
Date Gallons
3 Type of system. ❑ Cesspool(s) [t
Septic Tank ❑ Tignt Tank e Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yea,,._' Nc
5. Condition of System:
State COOe
��/
—V 0/40
Telephone Numbe
t — &COO
6. System Pumped By.
company
7. Location where�ontents were disppoo
1
S . Mc
Vehicle License Number
teform4.do0 03/06
Signature of Hauler
Signature of Receiving Facility
Date
System Pumping Recorc .Page .i
Pkom-F1/- /7545
- Commonwealth of M'assaphu etn s
City/Town of / Q f((A
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 :o
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:
Aker.Ailing out - System Location:
forms on the
computer use
only the tab key Address'
to make your
carscr-do not
City/Town Slate Zip Code
use the return
2. 2'7--2)A e
iv 4Q ('fai Li PIAIVi ?J
Address(If different from location)
City/Town
/�Zip Code
ep n Numb r l///
B. Pumping Record`ni�J
1. Date of Pumping ` ° gic �I �� 2. quantity Pumped: `� &O C
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ?ase Trap
❑ Other(describe): �"
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? 7 Yesr. o
5. Condition of System:
6. System 2-urmped By:
J
Company
7. Location where c
N
nts were di posed:
Vehicle License Number
Sign lure of-..er Date
Signature of Receiving Facility
t5fcrm4.doc•03/06
Date
System Pumping Record •Page 1 of t
I
Commonwealth of Massachusetts
City/Town of 1.0 /-(h.cria k-
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.
!..2 7n ii
U��
A. Facility Information
tent:
filling out 1. System Location:
on the
ner,use
le tab key Address
/e your
-do not City/Town State Zip Code
e return
2. Sy tern Owner:
f} YYl C r)ik-c
N me
1» 1 nw-, J S�
A dress(if different from location)
City/Town Star / o `
6 Zip Code
Telephone Number
B. Pumping Record
,cc� `
��y�pp I _ o o 1.l 0l 0
1. Date of Pumping Ddfe•u � ( 2. Quantity Pumped: G, ilIonnns
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank /Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? Yes ❑ No
5. Condition of System:
G-00-0
s. S fair
0...Na a Vehicle License Number
1,41 js 5,3e Goa
ompany
7. Location wher contents were disposed:
form4.doc•03/06
Signature of Hauler_ Date
Signature of Receiving Facility Date
System Pumping Record •Page 1 of 1