185 Pump Report 8-20-20Commonwealthlof Massachusetts
City/Town ofs e
System Pufnping Record
Form 4
Name:
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 Location:, 1
Maress p
...__MASS
City/Town tr` /" k— State
B. Pumping
1. Date of Pumoinc
3. Component: El ❑ Ces:
❑ Other (describe):
4. Effluent Tee Filter Present?
�
/� T ,'M` �' 2 Quantity Pumped:
5I(s) 0SepticTank ❑ Tight Tank
❑ Yes ❑ No If yes, was it cleaned?
5. Observed condition of component pumped
6. System Pumped By:
Name
CLEAN SEPTICS, INC.
Company
7. Location where contents were disposed:
BONDI'S ISLAND, INDIAN ORCHARD, MASSACHUSETTS
Signature of Hauler
Signature of receiving Facility (or attached facility receipt)
Zip Code
❑ 1000 (gal) /11� 1500 (gal.)
❑ Two Compartment Tank
❑ Yes ❑ No
ORANGE YELLOW/SILVER ,- MACK
11�, i
A Customer #
f ( Invoice #
TOWN COPY System Pumping Record • Page 2