595 System Pumping Record 2016 DO4
Commonwealth NJ4lsIsachusett
p City/Town of Vr4
sa_� 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.
A. Facility Information
Important:
when filling out System Locahonl
forms on the
computer,use
only the tab key Address
ycu'
o move do not
City/Town State Zia Code
use the return
key.
2. 5 stem Owner:
DrAJNn r y576%.��7 y�
Nameg35 Ca�> 1 �1Ertpau 5Z1✓i _—__
Address(if different from location)
City/Town � 3 3;o- O
�pryyP UUV r Tone Number
B.Pumping Record
1. Date of Pumping p� �� � � 2. Quantity Pumped
Gallons
3. Type of system: Cesspooi(s) eptic Tank ❑ Tight T nk J Grease Trap
❑ Other(describe).P❑CC77 --CWnP Cow TVG)
Effluent Tee F,Iter present? 7 Yes>1.21To if yes, was Y[ cleaned? E VentNo
5. Condition of System:
GoC30
6. System pumped By:
fUC\N�rpeV��) )(L / /n Vehicle License Number
,
mpany ('tW /
7. Location where contents were disposed:
Cis 6) •
Signature of Hauler Date
Signature of Receiving Facility Date
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