860 Septic Pumping Report 2012 Important:
When filling
out forms on
the computer,
use only the
tab key to
move your
not -do
use the
return key.
a
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
v 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
NORTHAMPTON /FLORENCE MASS
City/Town State
2. System Owner:
SHERRY ANN KUCHINSKAS
01060
Zip Code
Name
Address(if different from location)
State
City/Town State
230 9573
Telephone Number
Zip Code
B. Pumping Record
_APRIL 24, 2012 1500
1. Date of Pumping - - 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank II Cesspool(s) Trap
❑ Other
(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By.
FREDDIE
Name
CLEAN SEPTICS INC
Company
7. Location where contents were disposed:
BONDI'S ISLAND
SILVER/YELLOW HAULER L66-868
Vehicle License Number
Signature of Hauler
tbform4.doc•11112
Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record•Page 1 of 1