949 Septic Pumping Record 2009 Commonwealth of Massachusetts
City/Town of G ig?/e/rva -Ed 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
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
M move your
cursor-do not City/Town State Zip Code
use the return
key. 2 System Owner: y�
aame 0 � i UCL?
`4 H N Q Q21�
Ayerea�s if diffrent from location)
W ALL 7V �
City/Town
State fr
T phoni Number
Zip Code
B. Pumping Record
1. Date of Pumping
seQ1- 94400(
Date
2. Quantity Pumped:
jOcC
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap.
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes (�J�o If yes,was it cleaned'? Yes ❑ No
5. Condition of System:
GOW
Na e
>Q i s 5,-)e LOOkr.
ompany
7. Location wry><re contents were disposed:
NS
t5form4.doc•031D6
Vehicle License Number
Signature of Hauler_ Date
Signature of Receiving Facility Date
System Pumping Record •Page 1 of 1