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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 tsform4.doe.03/06 System Pumping Record •Page 1 of 1