575 Pump Report 06-26-19 Commonwealth as h setts ) � �
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City/Town of �I
System Pu ping Record
Form 4 Name: D
DEP has provided this form for use by Boards of Health. Other forms may be d, 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 w' in 14 day from the
pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
Address
MASS
City/Town State Zip Code___.,
B. Pumping Reco / ia��� / *"5"00 1. Date of Pumping: • 2. Quantity Pumped: ❑ 1000 (gal.) (gal.)
3. Component: sspool(s) [Septic Tank ❑ Tight Tank Two Compartment Tank
❑ Other(describe): Ir
4. Effluent Tee Filter Present? XYes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped
r
i
6. `ste Pumped By:
' RANGE YELLOW/SILVER MACK
Name
CLEAN SEPTICS, INC.
Company
7. Location where contents were disposed:
BONDI'S ISLAND, INDIAN ORCHARD, MASSACHUSETTS
Signature of Hauler du'46-mer,#
'00
Signature of receiving Facility (or attached facility receipt) Invoice#
TOWN COPY System Pumping Record • Page 2