96 Pumping Report 2017 o)Lifyi14-- AN- 1
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Commonwealth • -.M_ssach usetts
, i— City/Town of •• o 1./11
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t71System Pumping Record
To"t.- % Form 4
DEP has provided this form for use by soca. 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 tc
:he 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 1. System Location:
forms cn the •
computer,use
only the tab key Address
to move your
cursor-do not City,Town State Zip Code
use the return
key.
2. System Owner:
14:* ci4P-FPc--€- 4,/t
YC J
> r
Na�� cosLEirn(`' pour OD
PQM Address(if different from locatcn) t
City/Town l3one
3 ' T7
G (� Number
B. Pumping Record
1. Date of Pumping 1:2 t7 2. Quantity Pumped: tC :eGW s
3. Type of system: E Cesspocl(s) optic Tank [ Tight Tank ❑ Grease Trap
a `4'"Y E-1\11-- 611-i ' Ji O
❑ Other(describe):v-
4. Effluent Tee Filter present? Q Yes No If yes, was it cleaned? es ❑ No
5. Condition cf System:
cr )
6. S s�m�umped By:
N .e/, l' ` Sl'h'(..)
Vehicle License Number/l.LnJ11 1/, LiiLV'
Irlr
Company VC
7. Location where contents were disposed: •
ci\a_c_c_6") _
Signature of Hauler Date
Signature of Receiving Facility Date
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