993 System Pumping Record 2010 ,Z1// 00 '- 67V2-
Commonwealp o ass s tts
City/Town of/10 f�enitkvi
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 y ur
cursor-do not
use the return
key. 2. Syste�N Owner / - ,/ C
S aivs 4y�
IJarye Fi012. N C� !W,
City/Town
State Zip Code
Address Of different from location)
city/Town
B. Pumping Record
1. Date of Pumping
3. Type of system'.
StatueO 53,0If'�Qde
Tehone Number
1
RA-9410 2. Quantity Pumped: !Gallons
Date
l� Cesspool(s)
eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4 Effluent Tee Filter present? ri Ye
5. Condition of System:
If yes,was it cleaned? j:2s E No
6. System Pyymped By:
Na
Company
7. Location where contents were disposed:
t5farm4.doc 03/06
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility Date
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