427 System Pumping Record 2010 mportant
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Commonwealth of Massachusetts
City/Town of
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:
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Address
mfie Id
City/Town
2. System Owner:
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Name
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State Zip Code
Address(if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: Cesspool(s)
Other(describe)-
4. Effluent Tee Filter present? C--ves) No
5. Condition of System:
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Date
2. Quantity Pumped:
6. System Pumped By:
1500 C4
Gallons
Tight Tank Grease Trap
If yes, was it cleaned? No
Name
companE RVING WASTEWATER
7. LocationErfdirsL1N
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Signature of Receiving Facility
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Vehicle License Number
Date
Date
System Pumping Record•Page I of 1