38 Pump Report_Qx Commonwealth of Massachusetts
City/Town of
System Puniping Record
ForM 4.
DEP has provided this form for use by local Boards of Health. Mar foams' may be used, but the
Information must be substantially the some as that provided here. Before usin6thils-form, check With your
local Board. of Health to determine the form they use. The.Syptem 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
Important;
I• System Location:
when filling out
forms an the
-
-computer, use
only the tab key Address
to move* your Zip Code
cursor-donot mState. e
use the return
-------------
mn
-.5
Telephone Number
S. pumping Record
- A Qate
-ofPUmrAng
3, Type:of-system: PE -Cesspool(s)
0 other (describe):
4. Effluent Tee Filter present? 0 Yes
5. C,onditlon. of System:
Z. Quantity Pumped: Gallons
-Septic Tank 0 Tight Tank ❑ Grease Trap
2440 if yes, was it cleaned? Ye � o
6. Stem Pumped By
a a
any
7, Location where contents Were disposed:
signature of Hauler
Signature of Receiving Faclft
4 -
System Pumping Record., Page I IF I
j6form4.doc- 03106