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32 Title 5 Pumping Record 2009 t Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. Commonwealth of Massachusetts City/Town of /d G /—(2,/gyn-,o -Fr) )--i 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 1. System Location: Address City/Town 2. ystem Owner: H F1`11GldZ &ko Name 37 TrtAcla- Nt> State Zip Code Address(if different from location) City/Town State g2z. ip Code Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Cesspool(s) ❑ Other(describe): ptcgd Date 2. Quantity Pumped: Septic Tank ( 000 Gallons ❑ Tight Tank ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes m No If yes,was it cleaned? Yes ❑ No 5. Condition of System: ( 6. S —a ansa r /112 %S 5e.. fit' Nal?e ompany 7. Location where contents were disposed: t5form4.doc•03/06 Vehicle License Number Signature of Hauler_ Date Signature of Receiving Facility Date System Pumping Record •Page 1 of 1