58 pumping record 2017 Commonwealth of Mass-chusetts
•
gala _s_ City/Town of. i . - (� (-111,1,14-y�- '
t System Pumping Rec• rd
1111, Wit' 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 Hearth or other approving authority within 14 days from the pumping date in
acccrdance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer. use
only the tao key Address
to.rove your
cursor-do not
use the return City/Town State Zip Code •
key.
2. System Owner:
Y c c-uitn c
Nam
be Ed ,{6-ki LUNN
intro ` Address(if different from location)
MR&City/Town State Zip Code
AI CC Telephone Number
B. Pumping Record `
1. Date of Pumping r�' 7 ( 2. Quantity Pumped: ! OOO
Date Gallons
3. Type of system: ❑ Cesspool(s) _D.-Septic Tank E Tight Tank ❑ Grease Trap
❑ Other(describe):
•
4. Effluent Tee Filter present? ❑ Yes Vo If yes, was it cleaned? [ Ye .o
5. Condition of System:
Cks eqp
6. Si ped By:
/ iCief nG— Vehicle License Number
•�
Company
7. Location where contents were disposed: •
•
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 5 \\,41 (i)J avU t 1 System Pumping Record•Page 1 of 1
T