37 Pump Report 2019 ' Commonwealth of Massachusetts
_ Ci of r' x
City/Tow
Sy$tem •P'lu ivWl r g. RI 160 d.-
Form 4. -
DEP.has.provided this-fomyfor.use.by�locWBoards of Health,C*9r fiof ni i6iy.be used, but the
Infdrmation must.be substantially the spme.as.that provided here. B,Wbre`using,thli.f. check with your
local Board.of Health to determine the form,they use.The System iPuinping 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.
X Facility Information
17'
7 .
important:
When filling out 1. 'System Location:
s on the
_
form _ _ t
computer,use
only the tab key Address
to move your.
amr=do not C /Town State I Zip Code
use the return
key.
. 2. stem owner:
vi r
AddWs•(If differentt firm location)
city/Town• State
LL13 _ e
• � � �
Telepimne Number' .
B. Pumping Record
'Date.of.Pumping Fate .2.`4uantityfumped: Gallons
3,. Type,Of-system: ❑ -Cesspool(s) ' ?-tep'tic Tank' ❑ Tght Tank ❑ Grease Trap
❑ other.(describe):
4. Effluent Tee Filter present? ❑ Yes.• No If yes,Was it cleaned? .❑ Yes o
5. Conditio of System: Ip q
BMmpedy:
•
Vehide uc ense Number
O
any .
7. Location where contents•were disposed:
slgn"of NEIUIer: .., Date
Signature of ReoeMng Fad*
t9Y4mr4.doo.03/06 system Pumping Record-Page 1 of 9