312 System Pumping Record 2016 o(!//P- alJ )
Commonwealth ff ass c u ells
. City/Town of �► (1J p Act t i E�
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 sane as that provided hem.Before using this form,diedk 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
out 1.. System Location:
use
h key Address •
wr
I not . dlyRO.m Staff as Cada
run
2. Sy Owner. ry"� is T„—Z YA V V
N811e3'a Cke:srttSl&W Rip
Addresser different from lorfini)
Cityrravn
•iT6�S
T
B. Pumping Record
..\,6\1,
•1. 'Date of Pumping ate 3 l ,.2. Quantity Pumped: ,Gems
3. Type:of system: ❑ Cesspool(s) p-•Septic Tank ❑ TightTani< ❑ Grease Trap
❑ Other(describe): . .
4. Effluent Tee Filter present? ❑ Yes IG Na If yes,was it cleaned? .❑ Yes .2>W
5. Condition of System: / .
('-000
5. _ S6 e\ coped By.
cs `. sf � W elk,
7. licon wh> -were eispoeed:
U
i.doc 031106
Vallee License Number
Slgnema of Hmtler.
Signature of Rec&Mng Farley
System Pumping Record•Page 1 of 1