55 System Pumping Record 2009 •
Commonwealth of Massachusetts
r ' ,6 =0 City/Town of /"U o /—(2ignr-,� fa kf
__•'- System Pumping Record
age 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 not City/Town State Zip Code
return
use the return
key.
2. stem Owner:
cfrr< vs ON
cf5 CU )4 t`TTtn S+
Address(if different from location)
Ciity/Townr�, State Zip Code
FLuae C� Telephone Number
B. Pumping Record
Not)' 6o 9 SOU
1. Date of Pumping Da 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): 11
4. Effluent Tee Filter present? ❑ Yes L/J No If yes,was it cleaned? Yes (] No
5. Condition of System: I/
6. S
uzs
Na a •' Vehicle License Number
�nyts .5:]e. Gcr/r'
ompany
7. Location where contents were disposed:
SQ
Signature of Hauler_ Date
Signature of Receiving Facility Date
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