579 Septic Pumping Record 2009 •mss
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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
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System Pumping Record•Page 1 of 1