776 Pump Report 2019 Commonwealth of: Massachusetts
City/Town/TOWC1-.Of NorthamP ton
S � stem Rum h Record
Y. p:. : g
Fo=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:. . .
aci i y norma ion
Important:When: : .: .
filling out forms ::':1:.: System:Location::,
on the computer,.. .. .
use on y the tab . . .
key.to move your Add4W6 North King:Street : :
cursor-do not:
use the return, : � :" : ort eir-�bo_ton MA .. .. . '. . - --- - . . � --
key:
CitylTown�- - : State - Zip Code.
2.:. System..Owner:
:
. .. :Sandri Sunocco . ... . ... . .
Name-
...
Address(if different from location)
.:City/Town :: :. . :: State p.
. . Zi Code• .. .. .
n e Number
: . Telephon . . .:
B. Pumping Record:
9/6/201.9. . 1 500
1. : Date of Pumping 2.:Quantity Pumped: Gallons .
. . . Date: : .: .
3. ::Component:_ : ❑ :Cesspool(s) �. Septic Tank ❑.Tight Tank: ❑: Grease Trap:"
. . . .
❑ Othier(describe):
:4.: Effluent Tee Filter_present?.ql Yes:❑: No If yes,.was it cleaned? :Q Yes ❑. No
5. : Observed cpndition:of.component pumped:.:
:Ok:.
: .: . :6.. System Pumped By:
Nick:Beausoleil
Name Vehicle License:Number
Bostley Sanitary Service;:Inc.
: . .. . .. . .. .
::Company. . .. .. .
7. : Location Where contents were:disposed:: : : .
Gr nfield Wastewater Treatment Plant
/5%20.19
Signature of Haule Date
-Signature of Receiving Facility(or attach facility receipt): Date
t5forrn4.doc•11/12.: . : . : . : .: . System Pumping Record-:Page 1 of:1.: .