776 Pumping Report Commonwealth of Massachusetts
1---a-14 of Nonhampton
MISS 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 forms 1. System Location:
on the computer,
use only the tab
key to move your Address 776 North King Street
cursor-do not Northampton MA
use the return City/Town State Zip Code
key.
OM2. System Owner:
X Sanciri Sllnorco G s station
Name
mars
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1/10/2019 1,500
1. Date of PumpingDate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Z Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 1 Yes ❑ No If yes, was it cleaned? 0 Yes ❑ No
5. Observed condition of component pumped:
Ok
6. System Pumped By:
Nick Beausoleil
Name Vehicle License Number
Bostley Sanitary Service, Inc.
Company
7. /L/occcattiion� where contents were disposed:
Gr niiWlr ld Wastewater Treatment
Signature of Houle'. 0P019
Date
Signature of Receiving Facility(or attach facility receipt) Date
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