1 System Pumping Record 2015 Commonwealth of Massaqohus -t s /
City/Town of J�Jv a out
System Pumping Re�ord
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 yon:'
local Board of Health to determine the form they use. The System Pumping Record must be submi.aec tc
the local Board of Health or other approving authority within 14 days from the pumping date H.
accordance with 310 CMR 15.351.
A. Facility Information
Important,
When fining out 1. System Location:
Corms on he
computer, vse
only Me tab key Address
ro move your
cursor•do rot City/Town
use the rewrn
Key 2 System Owner
CI-IA IC, 10 1-1Wet-
Maness (if different from location)
State Zip Code
City/Town
ALI LIAR rn PT- 11
B. Pumping Record
yp ih1615
1. Date of Pumping
Telephone Number
Dale
2. Quantity Pumped.
Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
Verxi
❑ Other(describe)'.
4. Effluent Tee Filter present? Yes
5 Condition of System'.
c(62.--10u/t u L 11,
6. Sys} m,Pum d By:
600
Gallons
Grease Trap
If yes, was it cleaned? ❑ Yeii No
N a6/ IS S At/t
Company
7. Location where contents were di poged'.
slgeeeDire of Hauler
Vehicle License Number
Date
Signature of Receiving Facility
t51orm4.co •03106
Date
System Pumping Recom •Page '. or