259 Pump Report 2020N
commonwi6alto of Massiachusepfts
Ci*ty[Town of U� efrA
s:
System PuiTiping"Record.-
Form 4.
DEP has provided this formi for use by local Boards of Health. CAW fafts 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 apprd4ng authority within 14 days from the pumping date in,
accordance with 310 CMR 15.35.1.
A. Facitity Information
Important"
When filing out 1. System Location:
-forms on tha
computer, use
only the tab key
to move your,
cursor'- do not
use the return
Cityrrown state Zip Code
Cityrrown r it G n r. Zip.Code -
vim) — -/ I UI
Telephone Nr'
S.
Pumping Recor I
�G�
j.
Qete.of.Pumping Date ,.,2. Quantity Pumped:Gallons
3,
Type:of-systenl: ® Cesspools) Se -,E� �-'�ank El Tight Tank
El Grease Trap
E -F 1 2
CU
W
❑ other (describe):
4.
Effluent Tee Filter prase5!7�y El No if yes, was it cleaned?�-a Yes [3'N6
5.
Condition. of Syst em:
6.e mped By:
gae VeNcle License Number
0 any
7. Location here contents were disposed: 4 -
Signature of Hauler
'
Signature of Receiving Facility Data
i6fcrm4.doc• 03/06
System Pumping Record-" Page I of 7