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Commonwealth of Massachusetts ,,49444.A
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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
City/I-own
2. System Owner:
1 CT 6Z z H w l
State Zip Code
Name
13 - SV U�sr Kati u P.
pddfeep I(f different from location)
City/Town
Sta
T
T aphone Number
/Zjp Code
B. Pumping Record
,CDat Y g"
Date
1. Date of Pumping
3. Type of system: ❑ Cesspool(s)
❑ Other(describe):
Q<,/_
2. Quantity Pumped:
�Jop
Gallons
Septic Tank ❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
looQ
If yes,was it cleaned?
Yes ❑ No
6. System' Ptdmped By:
ia`&i$ tie Goof 'GW
Company
7. LocationiNhere contents were disposed:
IS
Vehicle License Number
Signature of Hauler
Signature of Receiving Facility
Date
Date
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