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