569 Title 5 Pumping Record 2009 Important:
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Commonwealth of Massachusetts
City/Town of rW o7----(2//v , -Fri )--1
System Pumping Record
Form 4
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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
1. System Location:
Address
City/Town
2. System Owner:
5(7Jthr,S C of tL-S
Name
EX 56 °1 M . r17013 pp
Tres yyerent from location)
t
ity/Town
State Zip Code
trf� /76,Te ephone Number
Zip Code
B. Pumping Record
tseQf 9309
Date
Date of Pumping
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
O9
2. Quantity Pumped:
,000
Gallons
Septic Tank ❑ Tight Tank ❑ Grease Trap
If yes, was it cleaned?
No
t5form4.doc•03106
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ompany
7. Locatio where contents were disposed:
)Ash ,
Vehicle License Number
Signature of Hauler_
Date
Signature of Receiving Facility
Date
System Pumpina Record•Page 1 of 1