864 System Pumping Report 6-23-20I
:+ Commoinw6alth of Massachuse;6
M City/Town of
G
: -
i.
Important
VMren iiNing out
forms on the'
computer, use
only the tab key
to move your
cursor do not
use the return .
keK .
DEP has provided this form for use by local Boards of Health. Other fohns may be used, but the
Information must be substantially the sgme as. that provided here. Before using this form, check with your
local Board. of Health to determine the fcrm.they use, The,System Pumping Record. must be submtbd to
the local Board of Health or other approving authority within 14 days from the pumping date in .
accordance with 310 OMR 15.351.
A. Facility Information
1. System Location:
2.
Address t
Clgy/rawn Staff Zip Cotte -
My/Town State ZIp.Code - �,
,1. Date.cf,Pumping � Data ' 3�w, . Quantity Pumped:aeoans d Q
3... Type'of-system: ' ❑ -Cesspool(s) epticTank ❑ Tight;Tank ❑ Grease Trap
❑ Other. (describe),L
4. Effluent Tea Filter present? ❑Yes No If yes, waa It clearied7 :❑ Yes Pio
5. Condition. of System:
"d4✓
. a
6 �Sys�te P. ped By
vehicle License Number
Zmany-«
7. Location where contend were disposed:
slab kveofHouler Date
gIgnab.ns of ReceMng Facility Date
Worm4.dac^ WIN System Pumping Recprd • Page t aF t