107 Septic System Pumping Report 2009 Important:
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Commonwealth f Ma sachusetts
City/Town of AJGJ2677i}5101/
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 ode"obi
A. Facility Information
1. System Location:
Address
City/Town
2. System Owner:
\h-\1/40 03d1SGN
�aO7 E.ST2 Fh7rt $11
dress(if different from location)
C,t VS
City/Town
State Zip Code
Srlg / 78 77 Zip Code
Telephone Number
B. Pumping Record
SeQ-V 2-09
1. Date of Pumping
Date
2. Quantity Pumped:
b 000
Gallons
3. Type of system: ❑ Cesspool(s) 4] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes 171 No If yes, was it cleaned? ['Yes ❑ No
5. Condition of System:
Ch N
6. System Pumped By:
X0253
�/
K� a-(C �''k � —
ompanv
7. Location where contents were disposed'
T
S )7
Vehicle License Number
re anler
Date
Signature of Receiving Facility
t5form4 doc•03106
Date
System Pumping Record•Page 1 of 1