89 Septic Pumping Records Important
when fining out
forms on the
computer.use
only the tab key
to move your
crier'-do not
use the return
key.
0'L /0-come.
Commonwealth of f a . ssch Setts
City/Town of • 1�i^.. (V(If /riiky6/
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health.Other fors 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. System Owner.
State
Zip Code
9 o
Address(If different from location)
City/rown
B. Pumping Record
Date of Pumping 57-11 - l 2. Quantity Pumped:
State,it
Telephone Number
9,Code
Date
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
666
Gallons
4. Effluent Tee Filter present? C Yes No If yes,was it cleaned? ❑ Yes
5. Condition of System: r
GC;vO -nTI,C-,5 - e;ss'- Act of) St )Aio urYSn32 u14LL —
ym 7oe — a'67-)0TTON1,
6. System Pumped By:
a e
is Sit wa(k,�
Vehicle License Number
a
mpany
7. Location where contents were disposed:
Signature of Hauler
Date
Signature of ReceMng Facility
tNGrm4.doo•03106
Date
System Pumping Record•Page 1 of 1
IL 0
I 0 c �'
:9 j v v
■L7 n/ C )11617 CF rye
Commonwea,l,��j of, Massachusetts
City/Town of/1/) Hivinia7ch
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:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return City/Town
key
q 2. ()stem Owner.
ame
t5form4 dac•03/06
Stale Zip code
Address Of different from location)
CityCity/Town jI If
B Pumping Record
1. Date of Pumping
42(/ /c' %Zip Code
ephone Number
oa't�e /V 2. Quantity Pumped: ) 000
Gallons
3. Type of system: fl Cesspool(s) Septic Tank 7 Tight Tank ❑ Gre se Trap
Lr Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑)kr If yes, was it cleaned? f'Yes E No
5. Condition of System:
)-1 G-4 LUYlTI fl
6. System Pumped By:
I�IITTII��a mme, �tU{.7�
Co
7. Lmooc1ation where contents were disposed:
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record Page 1 of 1