546 Pump Report 12-7-17 Commonwealth of Massachusetts
t' City/Town ofr�l+� telt
if- 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
use the return
key Cr1Y/r°wh State
Zip Code
2. System O� N+ner:
41/ ! omW 1`lv Sx)
1 J
Ad LI(��Y,CS(if diffSo
t from locetlons Q�
Cm/.own
lei . 3ao . 7 7 jip Code
ry.thiat �C(�
i _ - Telephone Number
B. Pumping Record
.1. Date of Pumping D�� I 2. Quantity Pumped: !`� a
Galbns
3. Type of system: ❑ Cesspool(s)po7Septic Tank 0 Tight Tank ❑ Grease Trap
I] Other(describe): �-COYJ76J vrrn rN - V L y 774l d 'I RS
4. Effluent Tee Filter present? ❑ Yes I7 No If yes, was it cleaned? ❑ Yes No
5. Conditipb.of System:
6. System pumped By:
GO 25
pima
el/4l/ Sl1 q /-/ n �/ Vehicle License Number _
•
C mpany
7. Location where contents were disposed:
•
Signature of Hauler Date
Signature of Receiving Facility Date
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System Pumping Record•Page I of I