623 Septic Pumping Record 2009 Important:
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t5form4.doc•03/06
Commonwealth .f Massachusetts Orr,
City/Town of (Jh4 y�
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
1. System Location:
Address
City/Town
2. S stem Owner:
t Yr) r1gTul-14
State Zip Code
a
Nc
Address Of different from location)
ok Nc_
ty/Town
State x1�
Te[cone N
umber
//zi/Code
B. Pumping Record
cc- 3O69
1. Date of Pumping
Date
2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) optic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
iSU �>
Gallons
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
If yes, was it cleaned? ,B'Yes ❑ No
6. System Pum ed B
a GY//q./`
6nyQ, ( -S
Company
PRE
fuo/1
7. Location ere contents were disposed:
Vehicle License Number
Signature of Hauler _
Date
Signature of Receiving Facility
Date
System Pumping Record•Page 1 of 1