20 System Pumping Record 2016 Immonwealth of assachu etts ILO- 2
:y/Town of
stem Pumping Record
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ecor 4fi- Win`
has provided this form for use by local Boards of Health. Other forms may be used, but the
rmation must be substantially the same as that provided here. Before using this form, check with your
tl Board of Health to determine the form they use.The System Pumping Record must be submitted to
local Board of Health or other approving authority within 14 days from the pumping date in
ct dance with 310 CMR 15.351.
Facility Information
System Location:
Address
City/Town State Zip Code
System Owner
f7ani „ PEW F,(EC sr
Addi�reesss(if different from location)
CItyftown
Slate Zip Code
Telephone Number
Pumping Record
Date of Pumping ��i� 2. Quantity Pumped: l600
Date
Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
Effluent Tee Filter present? ❑ Yes �No If yes, was it cleaned? ❑ Yes (
Condition of System:
(-CGO
System �mped By:
Na Alffic
Company
Location where contents were disposed:
Vehicle License Number
/D9
igfia Heide
of Houle
Date
Signature of Receiving Facility
Date
System Pumping Record• Page 1 of 1