421 Pump Report 12-13-17 Commonwealth of Massachusetts
�, CIty/Towp of tja-(. c.,
Jr. _ ,S stem' Pumping Rec rd
Forrtf4 '
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: 1
wren filling out 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. stem Owner:
I 0111_ N R )1 =alt cM Cl.SvT=n
NameLIA\ Nv )11A ilk PP
CM O Address(If different from location)
•City/Town Stale � Y (/d Zip Me
h &LL-O5 TtayphorNumber
B. Pumping Record
.1. Date of Pumping '"D�� I �� 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank �Firease Trap
❑ Other(describe):
Y
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No
5. Condition of System:
6. Syste��/(P���u1/mped By:
�I(�p^`V)
e e /•,D/c_vz 1 ` chide License Number
a,�0 Silt Y •
C mpany
7. Location were contents were disposed:
S —
Signature of Hauler Date
Signature of Receiving Fadlfty Date
•
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