583 Septic Pumping Report 2009 S /'d /-
ommonwealth of Massachusetts TV'
City/Town of G {21,9 ,0 Fr i
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
Important:
when flung out 1. System Location:
forms on the
computer,use
onl; the tab key Address
to move your
cursor-do not
use the return Cityrrown
key.
-� 2. System Owner:
r � N�1
Name
14...; COL CS' )7/ n-Docti J:fl
Adq ss(if d ftprent from location)
-ICI/rj/
City/Town
State Zip Code
in 27
Telephone umber
3 Zip((ode
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑ Cesspool(s) Septic Tank
C,H1'ILiC))
Date
2. Quantity Pumped:
❑ Other(describe):
.) 0u
Gallons
❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
Cy a -
6 5
t5form4.doc•03/06
If yes,was it cleaned? O Yes ❑ No
Name — Vehicle License Number
Agjs 5: )e t
ompany
7. Location there contents were disposed:
Signature of Hauler_
Date
Signature of Receiving Facility
Date
System Pumping Record•Page 1 of 1