291 Pump Report 2020CorTlmonweaft of MassAchus s
City/Town of
System .Pure ii Mrd ..
Form 4.
DEP has provided this form for use by'local Boards of Health. Other fohns 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.
her
the local Board of Health or otapproving authority within 14 days from the pumping date in -
accordance with 310 CMR 15.351.
A. Facility information
Important
When filling out 1. System Location:
.. forms on the
computer, use —._... _..__._
only the tab key
to move your
cursor- do not
use the return
key. 2.
ism
chyfrown State. Zip Code
Citynbwn
mate Zip Code�
Telephone Number
. Pumping Resor 11 r
' l ed: k V
1. ' D.ate.of,Pumping" ^. 2. 4uaYPum P Gallons
3,. Type: of system: ® Cesspooi(s) cTank ❑Tight Tank Grease Trap
❑ Other. (describe):
4.. Effluent Tee Filter present? ❑ Yes . o If yes, was it clearied? .11 yes
5. condition. of System: *' '
6. re�Frplld BY:'
'
a vehicle License Number
G mpany .
7. ( ocation where contents' were disposed:
sighoureOfHauler
. .., .
signature of ReoehAng Facility
s.
Mrm4.doc= 03106 system Pumping Record.° Page 1 of f