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551 System Pumping Record 2016 Important When OWm out forms ontu . computer,use ly the tab key to move your cursor-do not use the!atom Commonwealth achusp City/Town of 7 f i1 � System Pumping Record Fonn 4 DEP has provided this form for use by local Boards of Health.Oilier forms may be used,but the lnfomlaton must be substantially the sane as that provided here.Before using this form,dledt with you 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 torn the pumping date in - accordance with 310 CMR 15.951. o(!//P-i DIJ3, A. Facility Information 1. System Location: 2. Address dy/rown 95 ( Losze )cE. Y2PJ Mtoae tt dimes horn ionic) Z9 Code akffrows B. Pumping Record ocTP/d 6 ..z QeaM,a Pumtped: Dd. A. •Date of Pumping 3, Type:of system: :7 Cesspool(s) ,<Septic Tank 0 Tight Tank 0 Other(describe): . . . 4. Effluent Tee Filter present? 0 V 5. Condition System: (;-&o S Sygampytgpad By. tirfroi,S silt %/D& ) 600 0 Grease Trap If yes,was it cleaned? .0 Yep al‘ 7. Location vdt@r'e contents were disposed: taomvt.dco-0396 Vehicle License Number Signature of Heiler. _. , Slanetms of Receiving Fedly System Pumping Record•Page 1 of t