165 System Pumping Record 2010 f
Commonweal t�hh� oflvJassarrhusetts
to City/Town of/V, , I"?' C/z
System Pumping Record
Form 4
NO n/ C- PL-7 Wi
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
int
W g out 1. System Location'.
n the
el use
tab key Address
y ur
re urn
City/Town
a
2. System 0 ner:
) uwi aw Si-,
State Zip Code
Address Of different from location)
City Town
B. Pumping Record
I. Date of Pumping Oa- 0 1
Date
S p Code
Telephone Number
2. Quantity Pumped:
150D
Gallons
3. Type of system: '' Cesspool(s) er<eptic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe):
4 Effluent Tee Filter present? ❑ Yes If yes,was it cleaned?)2'4es [I No
5. Condition of System:
6. System umped By:
N"m
Company
7. Location where contents were disposed:
M U IV/1')i
Vehicle License Number
Signature of Hauler Date
Signature of Receiving Faclldy Date
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