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
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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
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�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