11 System Pumping Record 2009 vit. .; -Commonwealth of Massachusetts rer r• .. L
r ' ii • City/Town of /'V G I4 , ' -Fr/ n
1_ 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 flung out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the return City/iown State Zip Code
key.
}/'--- 2. System Ovfner:
Ya6 Vt 0 CONNtER
Name
i ( wW1`FTHZ sr
"�'°" Address(if different from location)
.Fl-o RE: NCl
City/Town State qV VZip Code
Telephone Number
,
B. Pumping Record ilia
CLTCI6C
p g 2. Quantity Pumped:
Date c(
1. Date of Pum In . uany umpe :
/ Gallons
3. Type of system: ❑ Cesspool(s) X Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): 2.
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Imo' Yes ❑ No
5. Condition of System:
6. S_tree �isia.eriar-
Name dr YYY/// Vehicle License Number
mpany S-fie GOOl
ompany
7, Location where contents were disposed:
Signature of Hauler_ Date
Signature of Receiving Facility Date
15form4.doc•03/06
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