52 Septic Pumping Records Important:
When Slog out
corms on the
computer.use
only the tab key
to Mae yow
=vac-do not
use the return
key
EX
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of
information must be substantially the same as that provi
local Board of Health to determine the form they use. The
the local Board of Health or other approving authority withi
accordance with 310 CMR 15.351.
y\✓
V°
the dmmay tastier
s. B fore uaingj�{ r. eck with your
st be submitted to
ping date in
A. Facility Information
1. System Location.
/rf-
�Za-�f
Addr�
er-
Cit town
2. System Owner.
Name
/ee,9'
State
o/o6.R —
Zip Code
Address(d different from bcaton)
City/Town
State Zip Coda
-sl/3 s�6 - s�o
Telaphona Number
B. Pumping•Record
1. Date of Pumping
one - L- 2. Quantity Pumped
3 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: ` / /
CI' �Sh P�7 /A/eci, Si-/Wein //VS-4C C
6. System Pumped By: /
Name
Superior Septic Services
Mc; oSo -7
Vehicle License Number
Company
7. Location where contents were dispose
i s _ C \-11‘^-
Signature of Haute
Signature of Rescuing Facility
telorme.doc•03/06
Data
Date
S �1� /0
System Pumping Record•Paget of I
Commonwealth of Massachusetts
ti City/Town of
op System Pumping Record
���-� Form 4
'�-s� 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 w•,th your
local Board of Health to determine the form they use. The System Pumping Record must be supmnteo io
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
Important
When Mop out
forms on the
computer. use
only esy
to 'a
your
wnw -oo not
uN Ne r tUr
Cey
IT .Asi lee
A. Facility Information
1 System Location. , )_
52 AWe'✓u n !A
A4« Ld p j- l /1
CM/Town State
2 Syst/ej Owner
_ _e P r✓ r VrS _J -__—_-
Name
Adamse(ir deferent horn location)
Chyrown
D/0G a
Zip Cow
--_-
State Zip Code
S�Nu SF 0.
reletacea NpmpM
S. Pumping Record
Date of Pumping
q�/ y-09 2. Quantity Pumped
Data
3 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe).
4 Effluent Tee Filter present? ❑ Yes t 'J No If yes, was it cleaned? ❑ Yes /No
5 Condition of System:
c013
❑ Grease T'ap
6 System Pumped By
ate °l r wzE_2_. _ _ :$ �J.
Vehicle Nam.
Superior Septic Services Ll—C-
Compwy
I L.nsb;ewn-ioc_Tun'l.--off
7 Location where contents were disposed' /
f[ Ny4t er .2
rttorme ooc 03106
Sign.ture of Heeler
&pnatuie of R¢dvinp Facilely Dale
System Pumping Rococo • Papa .•