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1368 Pump Report2017 Ntd • Commonwealth 0, M ssachusett City/Town of r System Pumping Record fit.0 Form 4 DEP has provided this form for use by local Beards of Heaith. Other forms may be usedbut tae information must be substantially tie same as that provided here. Before using this form, cneck with yo.,, local Board of Health to determine the form they use. The System Pumping Record must be submitted to the :oval Board of Health or other aporcving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information mportant: - Mien filling out 1. System Location: orms cn the ;omputer,use +nly the tab key Address o move your !ursor-do not Lit Tcwr ise the return y State Zip Coce • :ey. 2. Syste Owner: 14: kam meg /. AL ti._) TA8 P_m1V Xr� Address(if different from location) • City/Town Shat /" 3d0 Ziprpda� /l ' dam{(J Ted-pone Number • B. Pumping Record . • Date of Pumping Casa ll 2. Quantity Pumped: 7 Gallons 3. Type cf system: Cesspool(s) 12rSeptic Tank El Tight Tank Grease Trap E Other(describe): / 4. Effluent Tee Filter present? _ v`s If yes,was it c+eaneU l__ res tic 5. Condition of System: • j-lGHCCPG 6. Syste umped By: \._ 1014111. Nrimo �/(L/L 07/f.-, 1 Vehicle License Number 6mpany !f( 7. Location here contents were disposed: • • '�v\car Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record •Page 1 df 1