20 Septic Pumping Record 2015 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
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your A ress
cursor-do not NORTHAMPTON /FLORENCE MASS.
use the rel m
City/Town State
key.
�mm
2. System Owner:
TAD MALEK
Name
01060
Zip Code
Address(if different from location)
FLORENCE
City/Town State Zip Code
584 6744
Telephone Number
B. Pumping Record
1. Date of Pumping
SEPTMBR 22,2015
2. Quantity Pumped:
Date
1500
Gallons
3. Component: ❑ 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. Observed condition of component pumped:
6. System Pumped By:
LUIS
Name
CLEAN SEPTICS INC
Company
L66 868
7. Location where contents were disposed:
BONDI'S ISLAND INDIAN ORCHARD
l5fonn4.doc•11/12
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility(or attach tacility receipt) Date
System Pumping Record•Page 1 of 1