421 (VA Medical Center) System Pumping Record 2016 .01•
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System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other farms 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 iocal 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'.
„ -ing out System _.cation.
ferns an the
mperer,use _
only the tab key Address
cursor o more your
use the rat not Cityfown State Zip Code
he return
Re 2. SystemRRwner_
V tf m&p cr ti.
9A �bt 1 A-W si
Address Of different from location)
Cityfrown State ip Cotl
L
s �//.3 . 5—"y_ 0/o t 9 Xf zo
ELVTelephone Number
B. Pumping Record
ec
1. Date of Pumping Da 2. Quantity Pumped. Q
ns
3. Type of system: [ Cesspool(s) L Septic Tank ❑ Tight Tank „„.2"-O-rease Trap
❑ Other(describe).
4. Effluent Tee FAter eac,A? u_ ,eu _ if yes, was it cleaned? ❑ Yes 2Nc
5. Condition of System'.
C
6. Mem Pumped By
N Vehicle License Number
mpany
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Faci0ty Date
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