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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