407 System Pumping Record 2016 •
Commonwealth of Massachusetts
City/Town of Ivo t f I,4 g, �f
System Pumping Record
Form 4
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
Important:
When filling out System Location:
Forms on the
computer. use _
only the tab key Address
to mote yo r
cursor-do not City/Town State Zip Coos
use Me return
key.
2. ystem caner:
EX Name
tdrQ7 ttfDu afar dZ.(?
Address(if different from location)
Cdy/Town .t. t�i. /�C� Ai /ZiB Code
, .1 M pc Telephone Number
/ -` !/
Bill. Pumping Record
M l2� 1
1. Date of Pumping V a� �� 2. Quantity Pumped.
3. Type of system: Cesspool(s) Septic Tank ] Tight Tank G Grease Trap
❑ Other (describe): --- - —
4. Effluent Tee Filter present? 7-1 Yes J No ' If yes,was it cleaned? ❑ Yes c
• 5. Condition of System:
COM
6. stem Pumped By:
a@envi slit/t ,O J// /L%/n, Vehicle License Number
mpany /(Jf
7. Location wjrere contents were disposed:
cis J ,
Signature of Hauler Date
Signature of Receiving Facility Date
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