256 Pump Report 7-13-20Commonwealth of�Massachusetts
City/Town of r:''
lug
System Pumping Record
Form 4 Name:�P",�� t sp
DEP has provided this form for use by 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.
A. Facility Information
1. System
Address
City/Town
B. Pumping
1. Date of Pumoinc
3. Component:
❑ Other (describe):
4. Effluent Tee Filter Present? ❑ Yes
5. Observed condition of component pumped
6. System Pumped By:
Name
CLEAN SEPTICS, INC.
Company
MASS
State
Zip Code
✓.+' " `�""� 2. Quantity Pumped ❑ 1000 (gal) a` t'I
Septic Tank ❑ Tight Tank ❑ Two Corr
7. Location where contents were disposed:
BONDI'S ISLAND, INDIAN ORCHARD, MASSACHUSETTS
Signature of Hauler "
Signatureof receiving� Facility (or attached facility receipt)
1500 (gal.)
irtment Tank
If yes, was it cleaned? ❑ Yes ❑ No
ORANGE YELLOW/SILVER MACK
a
r°y fq,
Cusfomer #
Invoice #
TOWN COPY w° 7 e -y ; ' �, r x ,,% System Pumping Record • Page 2