36 System Pumping Record 2015 Important:
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c,./P/P- 170.a-
Septic
Commonwealth of Massachusetts
City/Town of ' f/T I h A /sip -Fr Ni
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
Qty/Town State Lp Code
2. System Owner.
o C76.-11‘ S •tmi1-t�TIa1
Na
AddremtH dtfferent from beaten)
City/Town
1GU 1111Apicd�l
B. Pumping Record
sta (j/ v7.15r,Zip Code
Telephone Number
-1. Dateof Pumping /p,--Dt'"' -{�� 2. Quantity Pumped: )co
3. Type of system: ❑ Cesspool(s)
❑ Other(desc )Pt
4. Effluent Tee Filter present? ❑ Yes
Tank ❑ Tight Tank ❑ Grease Trap
BalfalNt) T'S ffN MiliiVN cur TANK
ic 15" jp— 3 rgartom.
No If yes,was it cleaned? ❑ Yes No
5. Condition of System:
C,-c1(0- imp car 01-tY> m6&ft— Isa emo cn icm-ikeurn�
.itnt - I s rkke2l�t l�r lt+c -r 12)ktf cut acct clyc r tt)
6. j@ierAP,tlmped By: iTt(`-u' IASL i35, AC421630— h txte ca4WCGN 0 tyiLi
\V\ �1�� S'It �D/ Vehicle License Number
•
C mpany
7. Location re contents were disposed: « -
Signature of Hauler Date
Signature of Receiving Facility
tMOnn4.doc 03/06
Date
System Pumping Record•Page 1 of I