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Uommonwealth of Massachusetts
City/Town of W U (-(114p a fc
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 31a CMR 15.351,
A. Facility Information
System Location:
Address
City/Town
2. System Owner:
1--0QV-1
State Zip Code
Name
cI W b2(?
Address}(if different from location)
City/Town Stair/
Orre I ,dOC�IL
T Number
B. Pumping Record
1. Date of Pumping
()Cr 05
Date
2. Quantity Pumped
1 000
Gallons
3. Type of system: ❑ 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. Condition of System:
6aS)
7. Locatio where contents were disposed:
NS
Vehicle License Number
Signature of Hauler_
Date
Signature of Receiving Facility
5form4.doc•03/06
Date
System Pumping Record•Page 1 of 1