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547 Septic Pump 2016 Important When Iiigng out toms on the" computer,use only the tab key to move your cursor"-do nil use the ratan kW. Commonwealth of Massachusetts City/Town of - =Ftrs ✓ f System Purripin ' eEord - Form 4 DEP has provided this fomi for use by local Boards of Health.Other forms may be used,but the information must be substantially the serve as that provided hare.Before using this form,check with your local Board.of Health to determine the form they use.The System Pumping Record mist be submitted to the local Board of Health or other approving authority within 14days from the pumping date In - accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 2. CID/frown - zip Code itPE "(:1. Nana 5117 Pidralo KA) ( !ddrese'(a different from location) atyfrovni B. Pumping Record . ititx-1 Oats.ofPumping `� .` _ ��.,2. Quantity Pumped: tab eeires a Type.o€system: - ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe). 4. Effluent Tee Fitter present? ❑ Yes No If yes,was It ceaned? .❑ Yes ko • - 5. Condition of stem: t - / �(X . Vt 11l4:c u $TuPG-€ R ?tom 5 ∎Ws. 6. mped By. 1 frets silo' & f Vehicle License Number a%kn 7. Location_where contents were disposed: - aighebee at Hauler — • Signature of Receiving Fuggy hate - ttlpnn4.dac.03106 _ sys em pumping Remind•Page 1 of 1