183 System Pumping Record 2010 Commonwealth o/d v5aSSa S tts
City/Town of v (�
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
(local Board of Health to determine the form they utse,The System Pumping using
Record form,st 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
Ming out 1. System Location:
.n the
er.use g
tab key Address
e your
-do not
return
a
city/Town
2. System caner.
C u pGl
cir3 d
Address(if differen om location)
city/own
n-n i
B. Pumping Record
2. Quantity Pumped: calm
1. Date of Pumping Date
Tight Tank ❑ Grease Trap
tic Tank ❑ 9
3. Type of system: ❑ Cesspool(s) P
State
State
Telephone Number
Zip Code
zip Code
006
❑ Other(describep.
4. Effluent Tee Filter present? ❑ Yes
5. Condition (System.
If yes,was it cleaned Yes ❑ No
Vehicle License Number
Date
6. SWmped By:
Na e
Company
7. Laion 1befe contents were disposed:
Signature of Hauler
Signature of
t5form4.doc•03/06
Date
System Pumping Record•Page 1 of t