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
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