38 System Pumping Record 2009 Commonwealth of Massachusetts
jCity/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 substantially the same as that provided here. Before using this forrn. check with your
local Board of Health to determine the form they use. The System Pumping Record must be s.,bmmed to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
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A. Facility Information
1. System Location
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Address
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City/Town Stele l p Cod.
2 System Owner
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Name
Address(if different horn*cation)
Chy/Town
Sete Zip Code
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Tebpho a Number
B. Pumping Record
Date of Pumping D,/` /y-O q /sac)
1 2. Quantity Pumped Gallons
3 Type of system. ❑ Cesspool(s) X Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe).
4 Effluent Tee Filter present? [] Yes 74 No If yes, was it cleaned? ❑ Yesp No
5 Condition of System.
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6 System Pumped By
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Name
Superior Septic Services
Company
7 Location where contents were disposed
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Signature of Nwler
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vehic4 Liana Number
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Signature 0 Rec.iving Facility Date
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