96 Septic Pumping Record 2010 Commonweal ssachusetts
City/Town of '9' 17C/2
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 filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
City/Town
use the return
key.
2. System Owner:
QC MOCK a ji e- .
Name J Amur R9
State Zip Code
Address(if different from location)
City/Town
PMP
B. Pumping Record �Q '1
1. Date of Pumping C)Ctt " " /
rcifr-
Zip Code
Telephone Number
Date 2. Quantity Pumped:
2500
Gallons
3. Type of system: ❑ Cesspool(s) .eptic Tank E Tight Tank
g ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
6. System Pumped By:
eR�
Na
mpe
Comt any
7. Location where contents were disposed:
NS(�r
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
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