125 System Pumping Report 6-23-20tmportax* '
When tilling cut
farms'on the'
computer, use
only the tab ksY
to move Your
calor - do not
use the return
W. ..
Commonwealth of MassAth'useos
City/Town of
System .pi mpin Record -
For 4 . .
DEP has provided this form for use by local Boards of Health, Other fotms may be used, but the
InformeMorl must be substantially the slams as. that provided here. Before using this•form, ohs& with youe
local Board.at Health to determine the fprm they use. Thesystem Pumping Record must be submitted to
the local Board of Health or Dater approving authority within 14 days from the pumping date in .
accordance with 810 CMR 15.351.
A.
1. ' System Locatlon:
2.
cliyrrmun SVa Code
73p.code
cnyrrmn stem
mp
,
Date
. 2. Quantity Pumpe& i1, ' pate.of Pumping Data
3,_. Type:oFeyswrn: ' ❑ Cesspools) '�epticTank ❑Tightfank ❑Grease Trap
V ❑ other (describe),
rtk f 4. Effluent T80 Filter present? ❑Yes . No :If yes, wash cleaned? :❑ Yes No
5. Condhioon. of System:
B. VmPed By:. ,
Vehicle lease Plumber
any.
7. Location where contents were disposed*
AA\k /-(O
8lgnkirs of outer
signature of Receiving Fad*
Votm4..doc gS/0a
Date
System Pumping Recurd • Page t of 1