37 Septic Pumping Record 2010 k
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the some 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
Woe 1 System Location:
Woes filling out
forms on
computer..use
tet e
one key Address
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key se the fire fl maim -
key.
ick
2. System Owner
F loout`l
N'me3y 1`k s7
Address 01 different from location)
Slate Zip Code
City/Town Zp Code. -
Telephone Nunher.
B. Pumping Record
rJrii
1. Date-of Pumping 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s Septic Tank ❑ Tight Tank
Co f-Wv (AA-
Other -
❑ Other(describe): s V
r
4. Effluent Tee Alter present? ❑ Yes.l; No if yes,was it cleaned? ❑ Yes No
Date
IScO
Salons
❑ Grease Trap
5. Cord:ton of. stem: - _y
006 CCIrtR3s.1c
: �st�lle�
6. System Pumped By:
etisou hits
irke (S slit Wo(k, /9_539 (p
7. Locati where contents were disposed: >•
OminantiliAR,A
Signature of Hauler
Date
Signature of Recening Facility
taonn4.d0c 03/06
Date
System Pumping Record'Page 1 of 1