63 System Pumping Record 2009 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 suDstantielly the same as that provided here. Before using this form, check wnh your
local Board of Health to determine the form they use. The System Pumping Record must be submnled 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
Important:
When Nlinp oN 1
forme on the
COmp•M1er,win
only tM tab key • •
to move you;
aura« -do not
uw IN return
System Location:
SaL?Erfrgcn
ccJJ
Addrea�G CLEjt1CT
cMrt oown
2. System Owner.
if4 NI I EL
Name
G /6:6
LP Code
Address fa different from location)
CayfTown
shier . Zip Cod.
Telephone Number
B. Pumping Record
1. Date of Pumping beat - C� Z 2. Quantity Pumped: Gallons
0
3 Type of system: 0 Cesspool(s) M Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
a. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes $] No
5. Condition of System:
��
6. System Pumped By:
Mr's K c,C i t Lka a
Name
Superior Septic Services
Company
7. Location where contents re di,•.•sed
t 1 �C?ROZ.
Vwiiole theme Number
Signature of Hauler
Signets.of Reoalving
t5Iorm4.don 0V06
1c - a /-oq
Data
_._._w..... _.__._....
Dab
System Pump pq Record • Pegg : or