747 Septic Pumping Record 2011 .8 /-/P c??Itr 0 W.2-
Commonweal of jv]assachusetts
City/Town of D Sni/10h
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
Important:
When filling out .1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return
key„_ 2. System Owner: /
Tel 7 Pi oil e Ac
Address(if different from location)
City/rown
State Zip Code
City/Town
knin
efi3• Lis yeti
Telephone Number
B. Pumping Record
3- tl4t9f (
Date
1. Date of Pumping
2. Quantity Pumped:
(563
Gallons
3. Type of system: 0 Cesspool(s) ✓Septic Tank 0 Tight Tank 0 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes io If yes,was it cleaned? f/ Yes 0 No
5. Condition of System:
6. Systepl Pklmped By:
Vehicle License Number
e
Company
7. {fpcatinx$ere contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.dac•03/06
System Pumping Record•Page 1 of 1