34 Pump Report 7-13-18 1
-\ Commonwealth of Massachusetts
ai ,l City/Town of R n, A crst
N) System Pumping Record
--Al. 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 donot City/Town State Zip Code
ret
use the return -
key.
2. S stem Owner:
4U' ( OrS Q0r-asci
Name
a3u sylvocN �Nr
Address(if different from location)
City/Town State Zip Code
Fi-(lite N CI
Telephone Number
B. Pumping Record � j
1. Date of Pumping �`� 3 IE 2. Quantity Pumped: i O ---- --
�` Gallons
3. Type of system: ❑ Cesspool(s)) T❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
ID Other(describe): 9 c� y' N 4 TLN1
4. Effluent Tee Filter present? ❑ Yes No - If yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. System Pumped By:
Name- Vehicle License Number
Company --- -
7. h)Si-
where contents were disposed:
• 4�Ji
Signature of Hauler Date
Signature of Receiving Facility Date -
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