Loading...
595 System Pumping record 2015 Commonwealth of Massachusetts City/Town of NORTHAMPTON 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 wrtant:When ig out forms 1. System Location: the computer, ammaimm only the tab to move your Address sor-do not NORTHAMPTON /FLORENCE MASS. 01060 the return City/Town State Zip Code Xn 2. System Owner: WILLIAM RYAN Name Address(if different from location) FLORENCE City/Town State Zip Code 584 Telephone Number B. Pumping Record 1. Date of Pumping SEPTMBER 8,2015 1500 2. Quantity Pumped: Date Gallons 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ® No 5. Observed condition of component pumped: 6. System Pumped By: LUIS Name CLEAN SEPTICS INC Company 7. Location where contents were disposed BONDI'S ISLAND INDIAN ORCHARD L66 868 Vehicle License Number Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date 5form4 doc•11/12 System Pumping Record•Page 1 of 1