120 Pumping Report 2017 .__ .
n 14- 4,:1,N. J.
. •
, ,,,„.. Commonwealth • .-) :� sachusetts
fi_^,b City/Town of ���% &1' 4i-Ato44/1?-°(1"
w System Pumping Record
_/� Form 4
DEP has provided this form for use by local Beards 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:o
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 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not CitylTown • State Zip Code
use the return
key. 2. System Owner:
%or, �� esuo S , C /t1' ' '
Name
LSO (IKE'S MG` If ' PP
I
fallAddress(if different from looaticn)
City/Town
SL,t7✓ " 13 " I "de
(Mc � _GJ Telephone Number
B. Pumping RecordIRO
1. Date of Pumping 89Slit C? C� 2. Quantity Pumped:
Date Gallons
3. Type of system: [ Cesspool(s) Septic Tank ;_ Tight Tank ❑ Grease T-ap
❑ Other(describe)P,`(ss"""vooCNr aWTkiC
4. Effluent Tee Filter present? Yes ❑ No If yes. was it cleaned? es ❑ No
5. Condition of System:
acco
6. to Pumped By:
N e/, .% skJJi
aft/vi,
It
Vehicle License Number
Company
7. Locatio here contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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