21 Pump Report 7-13-18 i4:\ Commonwealth of Massachusetts
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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 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 City/Town State Zip Code
use the return
key. 2. A/7 stem Owner:
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XlnI1I NamEt�� y}� �1 V1 ✓T
,.�• Y ✓-A r V t I�;IK`U/ v*c Ks), _._...
YYYY Address(if different from location)
City/Town State Zip Code
Vi-dei r Telephone Number
B. Pumping Record cc
CD
1. Date of Pumping pat�w 12 18-' 2. Quantity Pumped: �Gelens
3. Type of system: ❑ Cesspool(s) .._ eptic Tank 5 Tight Tank ❑ Grease Trap
'E Barn 5 Other(describe): )— Q r 1 (\a-- V ai p-tku,-
4. Effluent Tee Filter present% JAI Yes ❑ No ' If yes,was it cleaned?Yes 5 No
5. Condition of System:
6. System Pumped By:
Name
Vehicle License Number
Company
7. Location where contents were disposed:
0gQ—
Signature of Hauler Date
Signature of Receiving Facility - Date
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