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Commonwealth of Massachusetts
City/Town of i C ( >. ,,r ieh
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
ocal Board of Health to determine the form they use. The System Pumping Record must be submitted tc
the iocai Board of Health or other approving authority within 14 days from the pumping date.r
accordance with 310 CMR 15.351.
A. Facility Information
System Location:
Address
City/Town
2. stem Owner:
w cp 1 ER
State Zip Code
Address Of different from location)
City/Town
473.5 t9-116 We
Telephone Number
B. Pumping Record
1. Date of Pumping
Dale
3 Type of system: ❑ Cesspool(s)
❑ Other(describe):
2. Quantity Pumped: j5Oo
Canons
Septic Tank _ Tight Tarx ] Grease Trap
Pain
4. Effluent Tee Filter present? r' Yes 7 Nc
5. Condition of System.
G
E
7
System Pumped By:
If yes_ was cleaned? n-Ye
Vehicle license Number
nts were dispo
Signatur auler
Signature of Receiving Facility
Date
Date
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