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