443 Pumping Report 2017 . Limh-1-- Ati. J
Commonwealth . .M_ssachusetts
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1�_-„►_ System Pumping Record
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W 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:o
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 1. System Location:
forms on the
computer,use .
only the tab key Address
to move your
cursor-do not City/Town State Zip Code
use the•eturn
key. 2. System Owner. ��
a-10r: WA1-Vo I
Na
ngq Dov e 120,
Address(if different from location)
City/Town S a J ._s ,i d/z. .97 •
)jrQk CE Telephone Number
(�' p[
B. Pumping Record •
+ 2'I t �j I l
1. Date of Pumping Date l` 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) _ - eptic Tank ❑ Tight Tank _ Grease Trap
J. Other (describe):
4. Effluent Tee Filter present? ❑ YesNe If yes, was it cleaned? ❑ Yes o
5. Condition of System:
GO
6. System Pumped By:
N: e j, ./ S I f , - (` 1/ Vehicle License Number
()(....
Company Il"11�U ytVl J►YI r
7. Location where contents were disposed:
s Q..
Signature of Hauler Cate
Signature of Receiving Facility Date
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