255 Pumping Report 2017 Ntd 174/11...7
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Commonwealthf n4,./ss achu��
=� City/Town of IvoIre 4
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System Pumping Record
Form 4 •
DEP has provided th.s form for use by local Boards cf Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, checK with you-
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 da:e in
accordance with 310 CMR 15.351.
A. Facility Information
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Important:
When`cling c..t . System Location:
forms on the
compute' use
only the tab key Address
to move your
oursor•co not City/Town S:ate Zip Code
use the return r
key.
2. /"1✓tem Orkl.l ' 411Nalfriqg
14,
s 1J—V sG12- .
Address(if dideren:from location)
• City/Town Siali _ /3 1. 7gde
Telephone Number
B. Pumping RecordMAk til
(566
1. Date of Pumpinc Date 2. Quantity Pumped: Ganons
3 Type of system: Cesspool(s) XSeptic Tank ❑ Tight Tank 7 Grease Trap
❑ Other(describe): I— CCM pRaTrnL T - V 4.
3 VS.
" 4. Effluent Tee Filter present% 2Yes No
if yes,was it cieanec? Yes Nc
5. Condition of System:
lT^'
5. System ?�mped By:
w(J�� Vehicle License Number
C5--f/Li
1C6mpany
7. Location where contents were disposed:
y - •
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record•Page 1 of 1
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