33 Septic System Pumping Report 2009 Pilmi (K/ 6"9
Commonwealth of Massachusetts
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 w'C1 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 o.her approving authority within 14 days from the pumping date in
accordance with 310 OMR 15.351.
A. Facility Information
Important:
When filling out 1 System Location'.
tuns an the
computer,use
ocly the tab key Address'
tO move your
cursor-do not
use the return
key
CityTown
2. System Owner'
diS D Pc .1C6
State
Zip Code
Address(if diihrent from location)
City/Town
,liar,Nut
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping t-] 2. Quantity Pumped: cal
3. Type of system: ❑ Cesspool(s) Vieptic Tank E Tight Tank ❑ Grease Trap -
❑ Other(describe): I r7Lec tkei S
t
4. Effluent Tee Filter present? Yes�No If yes, was it cleaned? ❑ Yeet No
"andit�o o S
5 n Tf fy`tem'.
�6 une,(5S
_y v ert}�y�nped By.
Na k D<bLJ
I 's Sr--e, LLYAL
Company
7, ovation wwJlere con
s were di posed:
Vehicle License Number
SignattaL ar Date
Signature of Receiving Facility
Date
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