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58 System Pumping Record 2010 Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. pIV/ ?jam- ( 7/.2 Commonweal of�V]assachusetts City/Town of I� 4tit/ch 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 1, System Location: Address City/Town 2. System Owner: c Y70 utne State Zip Code ` m- Savwe G-nn t.ln { Address(if different from location) City/Town Flx2G p ce State KW" 2Z Vic Code eepphone Number B. Pumping Record `f ‘,t•c¢nit) 1. Date of Pumping Date 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: ifttil-/ If go Gallons eptic Tank E Tight Tank ❑ Grease Trap If yes, was it cleaned? Yes _I No 6. System umped By: Nme b, Company 7. Jfation vypgre contents were disposed: S Vehic:e License Number Si nature of Hauler Sr nature of Receiving Facility Dale Date t5farm4.doc•03/06 System Pumping Record•Page 1 of 1