58 System Pumping Record 2010 Important:
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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
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