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25 Septic Pumping Record 2016 Commonwealth of Massachusetts City/Town of System Pumping Record - Fonn 4 - DEP has provided this form for use by local Boards of Health.Other?ohms 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 torn 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 SUN out 1. System Location: lemis on the computer,use only an tab key Address to move your cursor do not use the tekum citarown 2 l TEL CL stem Owner: /lddresa'(Ndlferer*tam braion) Ctyrravn B. Pumping Reco �" j. �. z. 4uanmy Pumped: . -1. 'Date of Pumping State Tie WOW 15c� C,eYOne 3. Type of system: - lc Cre-sspool(s) - ,Septic Teak, ❑ Tight Tank ❑ Grease Trap ❑ Omer(tlescdbe): " '/RS NE � `rC 4. Effluent Tee Flier present?(Yes 0 No 5. Conditon.of System: f (4) 6. . t raped By: If yes,was It cieaned? .es a No De, LS &of 7. L 1opwpgre contents were disposed: L4om4.doa 03N6 VeNtle Lkanse Number •_ Signature of Harder. Signature of ReceMng Featly System Pumping Rae rd-Pagel of t