551 System Pumping Record 2016 Important
When OWm out
forms ontu
. computer,use
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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