100 Title 5 Pumping Record, 2016 rmpo
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01V/P- iereW-3
Commonwealth of M ssech
City/Town of -
System Pumping Record -
Forn 4
DEP has provided this form for use by local Boards of Health.Otherfoims may be used but the
Information must be substantially the sane as that provided hers.Before using thiafirm,check with your •
local Board of Hearth to determine the fprm they use.The System Pupping 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:
2. System
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ra do DwnotL) ,
Seeker&deMat!eom brfbn)
mCode •
atyrown
-Q\AZTI-(13bi 1ooV),
B. Pumping Record
A. .Date of.Pumping 3k (C c..,2. Quantity Pumper `r;
Telephone Number
3.. Typa:ol system: W Cesspool(s) - ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(deecnbe). SSCEEQ �IN,I�tCTO12.
Effluent Tee Filter present? ❑ Yes j(,yflo If yes,was It cleaned? 0 Yea o
Condition of System: ///���
6
mped
7. Location where contents were deposed:
Sir
taoin&.doc 09106
Vehicle license Number
Stgnatine of Receiving Fanny
System Pumping Reocm•Page 1 of