167 Title 5 Pumping Record Commonwealth of assachusetts
City/Town of tr-nr bk1 a n JAI t3 MOW
System Pumping ecord
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. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return
key.
fa'OK
City/Town
2. System Owner:
rA�re? col �zronS
Tess f dlifer�entefrotfllocation)
Cit !Town �• 1 U 1.
State Zip Code
9K)z3Cmde
Telephone Number
B. Pumping Record T � Q
S W, 93 O I 2. Quantity Pumped: Gallons
1. Date of Pumping Date
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
PARP -
If yes,was it cleaned? ,Yes ❑ No
0. System Pumped By:,'
Company
7. L,0 bon where contents were disposed:
VE1L�License N ber
Q 6tb%tr'
t5torm4Aac•03/06
Signature of Hauler
Date
Signature of Receiving Facility
Date
System Pumping Record•Page 1 of 1