421 Pumping Report 2017 •
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Commonwealth of assa husetts
I=- City/Town of A ' MISS
—_mak
- "' System Pumping Record
�� =f 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 forms 1. System Location:
on the computer,
use only the tab -
key to move your Address
cursor-do not •
use the return City/Town State Zip Code
key.
2. stem Owne.= • /IV
r:
111E-Q CE-401--P
Name y-,frit4,1 coo
` v Address(if different from location)
City/Town — S t • 5gt/./ tim Zip Code 1't 2/2/00
T lephone Number
•
B. Pumping Record
RVd•ci17 0500
1. Date of Pumping Date 2. Quantity Pumped: Gallons
• x
3. Component: 0 Cesspool(s) ❑ Septic Tank ❑ Tight Tank _rease Trap
❑ Other(describe):
•
•
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes No
C
5. Observed condition of component pumped:
ro
C-°(1)
6. System Pumped By:
e_ S ` le
R r111 Vehicle License Number
Company
7. Location where contents.were disposed:
(mgq,
Signature of HaulerDate
Signature of Receiving Facility(or attach facility receipt) Date
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