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1339 Septic Pumping Report 2010 Importan : When filli g out forms on he computer,use only the tab key to move y ur cursor-d not use the return key. B H� /fir- 6 7/.2 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