15 Septic Pumping Report 2015 Impo nano
Mien filing out
forms on the
Commonwealth of M--ssachusetts
City/Town of ri .r( 4pvf�7'
System Pumpihh`"g 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 ycv
local Board of Health to determine the form they use. The System Pumping.Record must be submltte! Ic
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:
only the tab key Address'
to move your
cursor do not Gay/Town Stale Zip Code
use me return
'ey. 2 System Owner.
FoONDS
Name L5
h2442.. Sri
Address (if different from location)
City/own
b3 612111 Y?.rniMGIv
State Zip Code
Telephone Number
B. Pumping Record
2015 tEe 0
1. Date of Pumping Date 2. Quantity Pumped. Cations
3. Type of system. ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe). 0) ra-COnWHRT M lNi-8.`G U1-e2
IR itil p,W ALL
4. Effluent Tee Filter present? ❑ Yes If yes, was.it cleaned? E Yes,.l e
5. Condition of System&u 0053 ES) —
6 SSy stteemPumed By'
Naomi IS S�
Company
7. Location w re con
15Derma.does 03/06
s were dlspoged:
Vehicle License Number
Signature of Hauler
Sr
f Receiving Facility
Date
Date
System Pumping Recorc •Pag