833 System Pumping Records Impcnent
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Commonwealth of M'assachusett
City/Town of lik✓-rGi'g' fi—
'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 his form, check
tocsl Board of Health to determine the form they use. The System Pumping Recore must be s'uomitte: tc
me iocal Board of Health or other approving authority within 14 clays from the pumping date Ic
accordance with 310 CMR 15.351.
A. Facility Information
System Location'.
Address'
Cityrtown
2. Sylt.em Owner.
State
Zip Code
Address(If different from location)
City/Town
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B. Pumping Record
Vial \ l 1.5
Date
1. Date of Pumping
2..Quantity Pumped
Gaocs
3. Type of system'. C Cessp000i�(s) Septic Tank ❑ Tight Tank C Grease ?rap
❑ Other(describe)'. 9--011111PriZ -d1F1V1 C�
4. Effluent Tee Filter present? C Yes J" No If yes, was it cleaned? C Yeesro
5. /C^ondition of System'.
6. S stem rpped By D �+,��/'
is IS \S it .4•
Company
7. Location where con(epts were dispoged'.
Ne
Vehicle License Number
Signature of er
Signature of Receiving Facility
Date
Cate
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li
.ail ?ice 67V •
Commonweal o s tts
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
portant:
en filling out 1. System Location:
ms on the
neuter,use
ly the tab key Address
move your
Tsar-do not City/Town State Zip Code
e the return
2. System Owner
T 2Pc-14 rw-c\
3 u3 es-r Q OA 14,
�J Address(if different from location)
City/Town [I1�1 State / $I 2
mV Telephone Number
B. Pumping Record W -Pi U r wv
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: E Cesspool(s) eptic Tank ❑ Tight Tank J Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? J Yes [ No If yes,was it cleaned? es iJ No
5. Condition of System:
CI4-U
6. System Pumped By.
\
N m �`
•`
Company
7. t,pcatiw} re contents were disposed:
t5form4.doc•03/06
Vehicle License Number
Signature of Hauler
Date
Signature of Receiving Facility
Date
System Pumping Record•Page 1 of 1