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579 Septic Pumping Record 2009 •mss Important: When filling out forms on the computer,use onlg the tab key to move your cursor-do not use the return key. Commonwealth Qf Massachusetts City/Town of ttoviY 'h System PumpinRecord /V Form 4 rcr 7 '68 17 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 1. System Location: Address City/Town 2. System Owner: 3-, e FNam7"1 RotL t ct RQ Address(if different from location) State Zip Code City/Town FLoak ry ct State /_5/-• 00/0 Zip Code Tele)Shone Number B Pumping Record Date of Pumping nCf,300 el Date 3. Type of system: ❑ Cesspool(s) eplic Tank ❑ Other(describe): 2. Quantity Pumped 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: } I164N W,4 R1 6. System Pumged B, 00C) Gallons ❑ Tight Tank ❑ Grease Trap If yes, was it cleaned? Yes ❑ No RR A cc ( 3 4t 102 /L Company 7. Location where contents were disposed: NS6 Vehicle License Number Signature of Hauler Signature of Receiving Facility t5form4.doc•03/06 Date Date System Pumping Record•Page 1 of 1