326 Pump Report 2020�a
14 Commonwealth of M ssischuse,#ts
City/Town of
System .P4iTip1ng R6c6rd.
Form 4
DEP has provided this fomi for use by local Boards of Health. Other Tofft may be used, but the
Information must be substantially the ssme as that provided here. Before using this•form, check with your
local Board. of Health to determine the t'onn they Liss, The System Pumping Recordmust be submitted to .
the local Board of Health or other approving authority within 14 days from the pumping date in - '- .
accordance with 870 CMR 15.551.
A. Facility Information
,y
-"Important
Men innng out
.' -
1. System Location:
forms on the
_ canputer,use--
only the tab key
Address .. '
.
to move your.
..
ctesor-do not
City/rown 3lide. ZtP Code '
use the ratum
key
g• stem Owner
nw
.Name. �� pp // �� P� p��
3 ci'& . � dCg l^ �" / C'� '
Addr08'(R dtiterenrt from location) .
cityrrown stole n ZIp Coda .
Torwnh. Mimher .
S. Pumping Record,
A. D•ats.of Pumpingonim .. Quantity Pumped:. Gabns
3,. Type;ofSystem:. ®Cesspooi(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other. (describe): '
4., Effluent Tee Filter present? ❑ Yes � No If yes, was it cleaned? .❑ Yes LYN0
5. Condition. of System: 1
6. System mpad By
a e Vehicle Licenee Number ,
any .
9. Location where contents' were disposed: 4- '
Sigh re of Hauler. ...
signature of RemMng Faddy
Date
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