255 System Pumping Record 2011 ,a //t diwa
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Commonweal) of_JvJassa husetts
City/Town of `N'7/ 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
mportant:
Mien filling out 1. System Location:
orms on the
amputer,use
tnly the tab key Address
o move your
tursar-do not
City/Town
'se the return
teyq 2. System O ner:
rin
tom' me „„�� s 1�
55 s&)1t=
Address(if different from location)
State Zip Code
at
City/Town
rnp
B. Pumping Record
1. Date of Pumping D e4� ' ' 2. Quantity Pumped:
State Zip Code
Telephone Number
156D
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? es E No If yes,was it cleaned? . Yes 7 No
5. Condition of System:
00
6. ys em PtXnped By:
Na e
Cony
7. Location where contents were disposed:
NS
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility
Date
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