1339 Pumping Report 2017 •
•
Commonwealth of MssacbuPttP
•
City/Town of
y System Pumping Record
�r =
Form 4 •
•
•
DEP has provided this form for use bylocal 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 1. System Location:
Forms on the •
computer use _
only the tab key Address •
— — —
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. stem Owner:
Q J - C Z\J
Name 13q 2 Q V Q,t p) �
lt �
( J 1 CJ i
. Address(if different from location)
s
►�7C� o
City/Town N State Zip Code .
.57 Telephone Number
B. Pumping Record •
11/X9- (o 17 1,0 d0
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
•
4. Effluent Tee Filler present? 0 Yes t Jo If yes,was it cleaned? ❑ Yeo
5. Condition of System:
• G-oa9
6. SteaFmped By:
me. C (A)07 Vehicle License Number
• ompany
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record •Page ' of
it