203 Title 5 Pumping Record, 2016 A, Commonwealth of Massachusetts
Cityffown of
System Pumping Record -
Form 4
DEP has provided this Tani for use by local Boards of Health.Other forms may be used,but the
information must be substantially the same as that provided has.Before using thisfam,check with your
local Beard.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
rve�ien sang-ad 1. System Location:
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B. Pumping Record
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-1. Pate.of,Pumping •-,2. Quantity hrtped: Getoma
3, Type:ofsystem: - IC Cesspool(s) pilep&Tank ❑ Tight Tank ❑ Grease Trap
- ❑ Other.(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was It cleaned? ❑ YesrNo
5. Condition of System: ✓
S. : S -_P mped By:
s1
7. Location where dwntenb3 were disposed
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Wilde License Number
Gowns°of Reuter ...
Signature of Receiving Fadfipf
system Pumps®Record-Page 1 of