40 System Pumping Record 2010 p ///0? 6 7V,2
Commonwealth of assn /husetts
City/Town of JV(} �� h
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
nportant:
Alen tilling out 1. System Location:
rms on the
amputer,use
my the tab key Address
unoveyour
Arsor-do not Cityiown State Zip Code
se the return
z0. 2. stem Owner.
gin OToM -0
Address(if different from location)
C ty/rown
F-LttRt J q
B. Pumping Record
0
Date
1. Date of Pumping
State ZIT)Code
Telephone Number
2. Quantity Pumped:
t 0 60
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe)'
4. Effluent Tee Filter present' ❑ Yes No If yes, was it cleaned? Yes E No
5. Condition of System:
6. Systempumped By:
Name'y Vehicie License Number
Company
7. Location w re contents were disposed'.
4 " v
Signature of Hauler
Date
Signature of Receiving Facility
Date
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