609 System Pumping Record 2016 b
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Commonwealth of Massachusetts
City/Town of
System Pumping Record -
Fonn 4
DEP has provided this form for use by local Boards of Health.Cther?otme may be used,but the
information mgt be substantially the we as that provided here.Before using tldafonn,thedcwith your
local Board.of Health to determine the form they use.The System Pumping Record must be subintked to
the local Board of Health or other approving authority within 14 days torn the pumping date In
accordance Weft 310 CMR 15.351.
A. Facility Information
nt
a gad 1. System Location:
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2. System
Kt be9 & U N Yitr
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B. Pumping
Re_cord •
-0. "D.ete ofPumpin9 f G-.I : - r2. Qpantty Pmpart I Fe 6
3.. Type:ofeystem: - 1E Cesspv )soroyl( ) SepacTank ❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes.L}'No If yes;was It cleaned? .❑ Yes d4
5. Condition.of System:
6. �SyPin stem Pi
eV
By:
t wofk
7. Locelf when cones were disposed:
)mk.doc•03/08
YAW..License Number
arfae of#amen. -.
Signature of Receiving Farms
aygan Punphg Rea*•Page t of t