1339 Septic Pumping Report 2010 Importan :
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Commonweal tjb�/i of assachusetts
City/Town of f/ 't k/
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 Location:
Address
Citylfown
2, System Owner.
Cfr V' 07-
L `35 394 13 42, t--(0%
Address(if different from location)
State Zip Code
Cltyfrown
B. Pumping Record
1. Date of Pumping
0/M- 5 e / _/v / // CPb ./„
Telephone Number
f+06- 19 10
Date
2. Quantity Pumped:
3 Type of system: E Cesspool(s) Septic Tank
J Other(describe):
4. Effluent Tee Filter present? ❑ Yes 12''`o
5. Condition of System:
uo�
6. S stem iPtIrnped By:
ye
i
❑ Tight Tank
L5(-)
Gallons
Grease Trap
•
If yes,was it cleaned? Yes ❑ No
Company
7. LocatiRn were contents were disposed:
t5fonr4.doc 03/06
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility
Date
System Pumping Record•Page 1 cf 1