21 Title 5 Pumping record 2010 Commonweal) ofJV]as�sa� c�husetts
City/Town oflV� ithr-7—h
System Pumping Record
Form 4
DEP has provided this farm 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 City/rown
us the return
key
2. System Owner: /
y ) I , )1 10V))afr{,�
Name
. h% 'v)vS \NI)
min
t5form4.doc•03/06
State Zip Code
Address(if different from location)
City/Town
-� H )l�)
StataIF 5 !U/)
3 / c((/ Code
T/elleephon'f//Number
B. Pumping Record
1. Date of Pumping
Fi are r i 2. Quantity Pumped
3. Type of system: D Cesspool(s) eptic Tank D Tight Tank
E Other(describe):
4. Effluent Tee Filter present? L Yes 4' No If yes, was it cleaned,v Yes D No
U
Gallons
E Grease Trap
5. Condition of System:
�_L V )
6. Syste1m Pumped By
` '.
l \e•IIS )
Name
�(-
Company
7. Location where contents were disposed:
5 )'
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Facility Date
Ct
System Pumping Record•Page 1 of 1