1368 System Pumping Record 2016 •
Commonwealth sf _s .ac usett Ii
i
City/Town of 4� / /,A 4'' . ..4"/
"a ' System Pumping Record
rf a;r 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 RI nu out 1. System Locaton'
torTs on the
computer,use
only the tab key Address
o move yeH
ursor-tlno' gtyrf own State Zip Code
use the return
key
2 System Ow �r'. ����yy
N(P a lmme I Wl�.>d f T m i gra) Io) _
maiK Address Of different from location)
City/Town Stat c Zip Code
`ni l-1 r r l r 1p I o Telephone Number
B.Pumping Record
t(0
o0 O
1. Date of Pumping Cate 2. Quantity Pumped_ lGallons
3. Type of system_ ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
Other(describe). -- —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? E Y10
5. Condition of System:
FARO ctl-z
6. System Pytmped By:
p7+ee /
C Loo//r /// Vehicle License Number
mpany
7.
Location where contents were disposed:
yv s c
Signature of Hauler Date
Signature of Receiving Facility Date
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