47 pumping report d(6//0-DDIJ-si
1Zi, Commonwealth of Massachusetts
MCity/Town of �p)� {,ya,a I-4
r, i. 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 Pimping 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 16.351. .
A. Facility Information
^ `tg 1. System Location: - - -
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B. Pumping Record (�
• . -1. Date.of Pumping') Cl I6 2. Duan ty Pumped: ) a
3. Type Of.system: C .Cesspool(s) c Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? d Yes Lyn( If yes,was R cleaned? .❑ Yea Id'No
.../ a. . .
- 5.
((Condition of System: -
6. Systa7mped By:
Vehicle cage es Number
is sill wa/k,
7. Loation,wfiere contents were disposed: F
Signer of Hauler ,
—
StemluStemlessof Receiving FacilityFacilityDate
System Pumping Record.-Page 1 or 1
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