32 Title 5 Pumping Record 2009 t
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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