421 System Pumping Records Commonwealp otAassa s tts
0 City/Town of/U/} iIm
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 the Vocal Board of Healltth determine the
approving they use.The System
within 14 days from the pumping date inubmitted to
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return
key
Cityriown
2. System Owner:
c/JC tar
Nue9-k MAR) St
Address(if different from location)
State Zip Code
Ciiyfrown
Lecos
B. Pumping Recor
1. Date of Pumping
3. Type of system:
Telephone Number
m2 62. Quantity Pumped: s 000
ao to
❑ Cesspool(s) Septic Tank ❑ Tight Tank /O.-Grease Trap
3 O(Y
Gallons
0 Other(describe):
4. Effluent Tee Filter present? 0 Yes
5. Condition of System:
6. Systerp P,µrr}pgd By:
Name
Company
7 Location where contents were disposed:
oU CJ's 6j/
t5form4.do •03/06
If yes,was it cleaned?/f Yes 0 No
Vehicle License Number
Signature of Hauler
Signature of Receiving Facility
Date
Date
System Pumping Record•Page 1 of 1
f/P 67Wi7 7V/2
Commonweal of assachusetts
(a City/Town oft 2 ft 141-^1"
rl System Pumping Record h
Form 4
Important:
Wen Sarno out 1. System Location:
formson the
computer,use
only 4e tab key Address
to moue your
cursor-do not
use the return
key.
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 tc
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
tSform4.doe 03/06
City/Town
2. Sy tern Owner:
) osr1.)-
Yr7)7�Vtv
Address Of different from location)
Nam
City/ own
tip;OS
B. Pumping Record
1. Date of Pumping iri3) 0
Date
3. Type of system: 0 Gallons
�, Cesspool(s) ❑ Septic Tank
❑ Tight Tank rea
Gse Trap
0 Other(describe):
4. Effluent Tee Filter present? ❑ Yes 11;rdf, r
_ If yes, was it cleaned? j yes GI No
5. (Conditiyo"n�of System:
State
State
Telephone Number
2. Quantity Pumped:
Zip code
Zip Code
3a90 — 2 00
6. System Purzlped By:
Naln
Company
7. Location
e contents were disposed:
Signature ofHauler
Signature of Receiving Facility
Vehicle License Number
Date
Date
System Pumping Record-Page 1 of 1
Important
Wien filling out
forms on the
computer,use
only the tab key
to move your
censor-do not
use the realm
key
Commonwealth of Mchusetts
City/Town of /V e T!?_ka pf9i`
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 thisform,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
Qtyrrown State Zip Code
2. Tam lf-)l OwneIrdCF f f L
NamerIfIJ�i g�
Address'errr different from location)
Clty/rown
gT, t o fin 211
Telephone Number - '
B. Pumping Record`,�
14 V19,cl 2. Quantity Pumped: 5.(i C`
1. Date.of Pumping
3. Type of system:
Gallons
❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank Grease Trap
❑ Other(describe):
Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System: - "+
1,-DOn
If yes,was it cleaned? ❑ Yes ❑ No
6. U n i U'� s1 ,•/D/��n 1 • Vehicle License Number
�__- �' YlV .NY'�u-
7. Location when ntents were disposed:
111 r
ILform4.doc 3q8
Signor re of Hauler
Signature of RereMng Facility
Date
Data
System Pumping Record Paget of 1