11 pumping record 2017 •
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• .
.C . Commonwealth of tsAassachusetts
1-,- *- -- L,/ City/Town of
System Pumping Record
-- -5 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 thisibrm,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.
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• A. Facility Information .
. •
huportant
men/Ring out 1. System Location: -
„
forms on the
- computer,use
only the tab key Address
to move your
cursor--do not .
• Cftyfrown State zip Code •
use the neturn -
key. - 2.. System Owrier
7 '3-()V\VLG•t\) ' • .
. . .
•
Wall ) 1 C-WVA-1Z,Lon
• ".ddreser Of different from )
A.... Milinlin. •
• City(rown State zip Code •
•
-: • . ELta :,"00 -re Number'
• B. Pumping Record
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laN,
1• Dataof Pumping Dthe - - 2. Mandy Pumped: . . 'esions
. ".,.
. , . 3, Type'of system: • 0 Cesspooks) '. Septic Tank 0 Tight Tank 0 Grease Trap
• 0 Other(describe): I— Ci1,
&61----- 3 vias .
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4. Effluent Tee Filter present? Ei Yes/12' if yes,wasit cleaned? 0 Ye,p4io -
• -
. . 5. Condition of System: • ...
, G-0(k) • . .
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6. System Pumped By.
• 10 VA . - • ..._
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L5 s /i. kJ0,e.x..;;,,,..--- . Vehicle Uoense Number -
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7, Location 10ers Contents'were disposed:
. '\.)S V . •
Slilbitture al-levier Date
• • ... •
- - Signature of Receiving Facility • • DEP .
terorm4.doo• 6 \\ ic.) ‘sc4n ,\?......0.4(.. . „.6.4,13 c....
03/0 .i
System Pumping Record-Page 1 of 1
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