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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