64 System Pumping Record 2016 Commonwealth of Massachusetts
z City/Town of
System Pumping Record
Form 4
Important:When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key
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
1
System Location:r
4y k4 4cz✓w.s
Address
City/Town
Prl
2. System Owner:
ma�,r.t4ti
Name
/ '4
State
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Zip Code
Address Of different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
h6
Date
3. Component: ❑ Cesspool(s)
1. Date of Pumping
❑ Other(describe):
2. Quantity Pumped:
COO C,
Gallons
ptic Tank ❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes Et/op
5. Observed condition of component pumped:
YiC'rtf Lc
6. System Pumped By:
If yes,was it cleaned? ❑ Yes llo
M7? ?3,:)
Name Vehicle License Number
Companypv.,, err4tC
7. Location where contents were disposed:
Si u e o outer
Date
Signature of Receiving Facility(or attach facility receipt)
Date
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