29 Pump Report 2019 4
Common wealth oftMassschuseffis
City/Town o
Syst®m .P umwmg:Recur
Form'4.
a DEP has provided this form for use by'locai Boards of Health.Other Toims may be used,but the
information mue be substantially the some 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 810 CMR 15.851.
' A.. Facility Information
man
i9 i g out 1. 'System Location: i
forms on the' ( .
computer,use
only the tab key Address
to move your.
cursor:-duse then o not Wr State Zip Code key. 2. stem Owner:
+� 6 W
e•
AddMW-(N cifferat t from location)
City1rown ( state Zip.Coda
MwxWMIF, G1 A 'Telaphons Number •.
B: Pumping Record
A. `D,ate•ol'Pumping T �
I Data .2. Quantity Pumped: Gallons
r . 3. Type.af•systern: (� Cesspool{s} ❑ -Septic Tank' F1 11 Tank ❑ Grease Trap
❑ Other.(describe):
4. Effluent Tee Filter,.present? ❑ Yes, No' if yes,was it cleaned? .❑ Yes 0
5. Candition.oF System:
L
8. ' S ' mped By.
�,•� Vehicle Ucense Number
r
C&m
any
7. Location where gonteft were disposed: 4.
Signdiure of Hauler.I ... 4 pate
Signature of Reosh"Fad* Data
WornA.doo-08/08 -*stem Pumping Record-Page 1 of 1