185 Pump Report 2017 ,f7
4 /M-17?,04?- ,0 )
I .
_ ',.,. Commonwealth f ssachusett
-_rF City/Town of lr4 14 ��j11
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' ---i- , System Pumping Record
� 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 Health or other approving authority within 14 days from the pumping date in
accordance with 3"0 CMR 15.351.
A. Facility Information
Important:
when filling out 1. System Loca .on:
forms on the
computer.use A.
only the tab key Addressow-
:0 r ve your
cursor-do not
use the return City/Town State Zip Coce
key.
2. 4stem Owner:
• i
Name ties CSP INpot, 1J okk
Address(if different From location)
Cityfro�wtn We, $ t1 1 ..,45,2ode �/
FJ 1.j r ce e eahone Number V Q
B. Pumping Record
2.f,t7 16'66
1. Date of Pumping ate to 2. Quantity Gallons
3. Type of system: ❑ Cesspcol(s) • ❑ .Septic Tank C Tight Tank ❑ Grease Trap
❑ Other(describe): ?life a a cgt06C+R s?-Luc1 =N3-Gcrr12. Ve ( M a4)
4. Effluent Tee Filter present? ❑ Yes No - If yes. was it cleaned? ❑ Yes,,,, o
'5. Condition of System:
11110 Se-Wen- (cs ?urn
6. Systzrped By:
N ewitio slit too/7r��%�/✓ Vehicle License Number
kaimpany
i
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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