242 System Pumping Record 2010 .Eil c??J 67V)-
Commonwo ilme/s k�tts
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City/Town of D
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
ant:
'tiling out 1. System Location:
m the
ter,use
e tab key Address
e your
-do not CityRown
t return
2. S stem O ner:
f e\i Foe
Ltae SyVt Sn 07 1242)
Address(if different m location)
State Zip Code
City/Town
-9
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system:
2. Quantity Pumped:
15 CrO
Gallons
❑ Ce spool(s) eptic Tank P Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Conditianpf System:
6. Sys emP ed By:
Name
If yes,was it cleaned? Yes ❑ No
Company
ii7. Legation w e contents were disposed'.
arma doc•03/06
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record•Page 1 of 1