54 Pump Report 2020Q, Commonweal K f Ma s chusetts ,r
City/Town o P/ % f �� l�
a System Pum ing Record
Form 4 - Name:
(g)
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DEP has provided this form for use by Boards of Health. Other forms may tie 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 approving authority within 14 days from the
pumping date in accordance with 310 CMR 15.351.
A. Facility Information
1. System Location: ,r— /
Address dz�/ �J
i
MASS _
City/Town^" State
B. Pumping Re�ol l� Ol � (�/��„
1. Date of Pumping: t. 2. Quantity Pumped:
3. Component: ❑ Cesspool(s) f�6 Septic Tank ❑ Tight Tank
,
❑ Other (describe):
4. Effluent Tee Filter Present? ❑ Yes D No If yes, was it cleaned?
5. Observed condition of component pumped
6. System Pumped By:
Name
CLEAN SEPTICS, INC.
Company
7. Location where contents were disposed:
ONDI'S ISLAND, INDIAN ORCHARD, MASSACHUSETTS
Hauler
rq(of receiving _acility (or attached facility receipt)
COPY
Zip Code
❑ 1000 (gal.) w 1500 (gal.)
❑ Two Compartment Tank
❑ Yes ❑ No
RANGE YELLOWISILVER MACK
l
(�j Customer #
7 '1 6
Invoice #
System Pumping Record • Page 2