421 Pump Report 2019 (2) Commonwealth ofmas*sjschuss
City/Towof
System •PUiyfpa n•g •R6e0rd
Form 4
i DEP has provided this form for use by'local Boards of Health.Othef fotms may be used,but the
informatiori 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 1. System Location: ..
forms on the'
computer_use _
only the tab key Address
to move your
cursor=do not C1ty/Town State Zip Cade
use the return
may' 2. System Owner
Name.
t
�0 Address•(fi:d'rffarent from location) - - --
cityrrbwn State Zip.Code
Telephone Number' �((�
B-Pumping Record
m1. 'Date;of.Pumping Date :.?. Quantity Pumped: Gauons
3, Type.of•systern: ❑ -Cesspool(s) ❑ -Septic Tank ❑ Tight.Tank Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes;2:"No If yes,was it cleaned? .❑ Yes No
5. �C..00nndition.of System:
6. em meed By:" •
Zdany"L' 1 Vehicle License Number
AX
7. Location where contents were disposed:
Siginature"of Hauler. •• t Date
Signature of Receiving Facility Date —
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