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417 System Pumping Record 2009 Commonwealth of Massachusetts City/Town of AK D T—(2i 4p )--t System Pumping Record Form 4 n M74 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 31 P CMR 15.351. A. Facility Information ing out 1. System Location: the r,use tab key Address your to not slum City/Town t 2. ystem Owner: ��77 �-y_ I CRe o/` t Name X17 t,up-ccTrwii n 2f) Address (if different from location) Slate Zip Code City/Town Ftorf t?N c,C� B. Pumping Record 11r5�. �y Date of Pumping `v l` `Qct Date 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: 6 doe.03/06 Ste q ' — ST� Zip Code Telephone Number 2. Quantity Pumped eptic Tank LOGO Gallons ❑ Tight Tank ❑ Grease Trap If yes,was it cleaned Yes ❑ No — ="as∎•=_∎� �n�:__� �Na e LK SrQt ✓Wrt caRe ompany 7. Location where contents were disposed: Spr Vehicle License Number Signature of Hauler_ sate Signature of Receiving Facility Date System Pumping Record •Page 1 of 1