9 Septic System Pumping Record 2001 Important:
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Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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 L
dress
NORTHAMPTON
City/Town
2. System Owner:
HILLARY SHAW
Name
MASS.
State
01060
Zip Code
Address(if different from location)
State
City/Town State Zip Code
530 0499
Telephone Number
B. Pumping Record
1. Date of Pumping NOVEMBR 11, 2. Quantity Pumped: 1500
2011 Gallons
3. Component: Cesspools) ® Septic Tank 11 Tight Tank ❑ Grease Trap
❑ Other
(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? ® Yes ❑ No
5. Observed condition of component pumped:
ALSO DONE 2009 AND CLEANED THE FILTER THEN TOO
6. System Pumped By:
FREDDIE
L66 868
Name Vehicle License Number
CLEAN SEPTICS INC
Company
7. Location where contents were disposed:
BONDI'S ISLAND INDIAN ORCHARD
Signature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doe,11/12
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