41 System Pumping Records Commonwealth of Massachusetts
City/Town of " N Q(41.4. -4an
System Pumping Recor
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
Important:
Wien Oiling out 1. System Location:
fonts on the
computer.use
only the tab key Address
to move your
cursor-do not . City/Town
use the return -
key. 2. System •_ er
Firmfl2G 2)e-i'(es
Name L, ( 4�
V Y 2-R
Addreas pr different from location)
State
Zip Code
Ciylrown
B. Pumping Recor
Telt W7 Lp COde .
Telephone Number
° I000
.1. Date of Pumping amt Quantity Pumped: ca0
3. Type.of system: ❑ Cesspools) - Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Fitter present? ❑ Yes No If yes,was k cleaned? ❑ Yes No
5. Condition of System:
C ve'cQ
e. gSyste tPtunped By:
p1 �11J�
fir 115 ^i;t Wo i Vehicle acense Number
7. Location where contents were disposed:
0t> SQ
Wformd.doc•03/06
Signature of Hauler.
•
Signature of ReooMng Faddy
Date
Date
System Pumping Record•Page 1 of 1
'- weaan or Massachusetts
City/Town of /'V G 1--(2t,g7,,,o
System Pumping Record
Form 4
1" •Li I.
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
'D ant:
en filing out 1. System Location:
's on the
tputer,use
the lab key Address
love your
.or-do not
the return City/Town
A
2. System •wn r:
el ow fre-fixiic tgo,
A dr¢ssss(if d ffffer from location)
L /f
City/Town
B. Pumping Record
State
StSScy ?umber)
TefephLe Number)
Zip Code
Zip Code
1. Date of Pumping 0 )�� 0
Date 2. Quantity Pumped U
3. Type of system: ❑ Cesspool(s)
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
6
Gallons
eptic Tank ❑ Tight Tank ❑ Grease Trap
If yes, was it cleaned?
1.doc•03/06
mpany
7. .ocati(o'n w e contents were disposed:
(`Il J 1�r
Signature of Hauler
Signature of Receiving Facility
Vehicle License Number
Date
Date
System Pumping Record•Page 1 of 1