82 Pump Report 2020Commonw®alth of Massaqhu�sertts
City/Town of Kdtq d 2
SystemP4nfping Rec rd.
Forma 4
DEP has provided this form for use by local Boards of Health. Other Wins may be used, but the
Information must be substantially the spme 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 810 CMR 15.351.
A. Facility inforrmiation
.. Important: ' s-
- When filling out _. 1. System Location:
farms on me_...._. --
computer, use
only the tab key Address
to move your.
cursor -do notCitylrown State, Zip Code
use the return
key. 2. System Owner'.
Q Gnf�'�!� �yt�irZ 1
. Nam O O, CCU�-1.,� d )Cl 440ow OW
Addross'(fr different from location)
B
City/i'own state code . .
Lh-5�la Ipg'
Telephone Number'
D,ats.of,Pumping
Type: of system: JE
❑ Other (describe): O,f
Date r:.2. Quantity Pumped:. rGallons
Cesspools) Septic Tank ❑ Tight Tank ❑ Grease Trap
4.. Effluent Tee Filter
5. Condition of System: (7
6. SZ ys.a Pumped By
�U �el��a
C any ,
7, g�L,o``cation( )here contentswere disposed:
vV�
SlgmAure of Hauler . ...
Signature of Receiving Facility
tfifonn4.doc 03/06
If yes, was it clearied? es 0 -'Nb
Vehicle Ucense Number
Date
M
System Pumping Record.• Page f of i