520 Septic Pumping Record 2011/15 0. (//0- taus,
Commonwealth of Massachusetts tic
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be 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
Important:
When filling out 1. System Location'
fors on the
computer.use
only the tab key Address
to move your
arson'-do nat City/Town
use the return
key. 2. stem Owner
X" KE LLE EV
Zip Code
?man • t/] 3217172-6
LEx - Telephone Number
B. Pumping Recor
1 & G
-1. Date of Pumping ti 15
u -2b Data 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Fitter present? ❑ Yes No If yes,was it cleaned? ❑ YeNo
5. Condition of System:
6. Seem Pumped By
5 work Vehicle Clone Number
gic Sfle '
matey
7. LpcI ation where meets were disposed:
� S
Sig of Hauler
Date
Signature of Receiving Facility Date
tgomn4.doo•03/06 System Pumping Record•Page 1 of 1
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor:do not
use the ret rn
key
vi1 -6Ke'7
Commonweal '�of.4assa husetts
D
City/Town of/ "--/-ch
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be 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:
Address
City/Town
2. ySyy ristem/Owner: 1 f
A ELLr!'1a r
Name
59-0 Th 6 c N
State Zip Code
Address Of different from location)
City/Town St
Leeps
• 73.2
YpCode
Telephone Number
B. Pumping Record
-�;t,i � /
1. Date of Pumping
Date
3. Type of system: D Cesspool(s)
D Other(describe):
4. Effluent Tee Filter present? D Yes [ No
2. Quantity Pumped:
fbOO
Gallons
[Septic Tank D Tight Tank D Grease Trap
5. Condition of System:
6. System Pumped By:
If yes,was it cleaned? Yes D No
Company
7. Location ere contents were disposed:
\,
�
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility
Date
t5form4.doc•03/06 System Pumping Record Page 1 of 1