836 Title 5 Pumping record 2010 f o / X79
Commonweal of JvJassachusetts
City/Town of nod
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
Important:
When filling out 1
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
birm
SVccation'. a / ` n'e 62
A es G1,74'/// I,�IC/'�
City/Town (/! State Zip Code
2. Syst 0)771:
/LL i% /.g bp/IQ—_
Address(if different from location)
City/Town States
Lip Code
Telephone Number
B. Pumping Record
4W
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: E Cesspool(s) , Septic Tank ] Tight Tank ] Grease Trap
] Other(describe):
4. Effluent Tee Filter present? E Yes I] No If yes,was it cleaned? ❑ Yes ] No
5. Condition of System.
6. Systr P mped By:
Na
G mpan'y �f—3
/ 2 (.i./6
7. Loy/tJo n h e contents were disposed:
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1