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. Commonwealth of Massachusetts
CitylTown of
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 suOm¢led Io
the local Board of Health or other approving authority within 14 days from the pumping dale In
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
• Adam
er 4CC
Cltyrtown
2 System Owner. \
yMi i i`9JS
Name
Address(a different from Iocadonl
City/Town
State
2-Fri Cb3Lip t
0,00 liCod.
p Coda
State Zip Coda
q/3—SXF—zSi
Telephone Number
B. Pumping•Record
1 Date of Pumping �— a - 2. Quantity Pumped:
3 Type of system: ❑ Cesspool(s) _Septic Tank
❑ Other(describe):
4 Effluent Tee Filter present? ❑ Yes ❑ No
5 Condition of Syste .
6. System Pumped By:
13cAr� e.,(
Name
Superior Septic Services
Company
7 Location where contents were disposed:
\IXNhr, ctic V i' CO c-
❑ Tight Tank ❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
t510rmea0.03/06
Sionle of Meeker
Signature of Receiving Fedliry
2ec 1i2.1 1 111 A
z._.7F9... iy\ cNJ
Y --IO7
Vehicle Liao Number
1-2— t (
Date
/— 1/ -»
System Pumpirp Record •Pape of 1
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, Commonwealth of Massachusetts
City/Town of
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
1 System Location: L/J��-��
AAdres. tO� / /cad
FAA-NC 54
City/Town Stab Zip Code
2. System Owner
mO
D!w %R/OS __ Tou L
Name
Address(If afferent from location)
City/Town State
Y
-
Telephone .IMDW
Zip Code
B. Pumping Record
1 Date of Pumping /'`10 2. Quantity Pumped: -. 1. PO
Date GNlona
3 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe). —
4 Effluent Tee Filter present? ❑ Yes Orblo If yes, was it cleaned? rt Yes Y' No
5 Condition of System:
1s_ ce
6. System Pumped By:
yoyo7
Nams 'T J
vehicle License Number
Superior Septic Services
Company
7. Location where contents were disposed. �7�J�^�CO (�c_pwK-� t�\'P"n'6"
)1^ riita
Signature of Hauler Dad
Signature of Receiving Facility
Slorma doe.03106
G 7- 1 �
Date
21-?oS System Pumpag Record•Page t of 1