421 Pump Report 4-11-18 •
Commonwealth of Massachusetts
4 r City/Town of • � T ( Qv
i System Pumpi g cor
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
Men Hang out 1. System Location:
tarns on the.
computer,use
only the tab key Address
to move Your
aesor-do not - CIIymown Stat Z3pCode
use the mem
S' 2. System Owner. Tvitt
Hameikak all-t i
Addres-s`s'Off different from mention) // ) �/ '/
Clrymawn •
t7 J 7-47 4/ —( OLZIP /�
alapiwraMareer
B. Pumping Recor
A. Date ofPumpingDate2. Quantity Pumped: alone
- 3. Type.of-system: E Cesspool(s) ❑ 'Septic Tank ❑ light Tank _MOease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was lt cleaned? .❑ Yes ❑•No
5. Condition.of System: - +6:00D-
6.
cD8 va�eJd�ajr }J,���1�roped By: q ly -
tMe.I3' ',�i1C- Vehicle License Number _
7. Location where� contents were disposed:
s U p^
Slgnahae of HauIer Date
Signature of Receiving Facility lata
taomM.doa•0.3138 System Pumping Record•Page 1 of 1