17 System Pumping Record 2009 Commonwealth of Massachusetts
City/Town of WO (-(1,7A 'k 'i
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.
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A. Facility Information
1. System Location:
Address
CltyrTown
2. System Owner:
(-/Ce PerfefilACk
Name /Ictam�// Q �f/�_+ep^�`�,p%� //J 3
Andre 9s(NdlNerent from location) / U��
w 9!l/ 4st42P_
Cit
State Zip Code
Slate �6 ip Code
� L/7er
T e hone Number
B. Pumping Record
1. Date of Pumping
5137/
Date
2. Quantity Pumped:
/2,--27o
Gallons
,,� Grease Trap
3. Type of system: ❑ Cesspool(s) r� aeptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes E,—,-C— If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Na e ` �
4Kis f
544 t ,)072
ompany
7. Location where contents were disposed:
/l2,Y-66iYf �
Signature of Hauler_
Signature of Receiving Facility
DC'03/06
Date
Date
K
System Pumping Record•Page 1 of 1
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