983 Pumping Report 2017 ei.-/p• 0/,-- 'U
Commonwealth,
D� �9sachus��etts
=W City/Town of f
_cp System Pumping Record
1 Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
with your
information must be substantially the same as that provided here. Before using g this
Record must beh submitted your
to
local Board of Health to determine the form
theyuse.
within 14 days fropmng the pumping date in
the local Board of Health or other approving �'
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1 System Location:
on the computer, —— —.-
use only the tab Address
key to move your
cursor-do not Stat Zip Code
use the return CitylTown
key.
2. System Owner:
ablin '. ..I
Name
IF ct, 3 enc w.c:, Op
Address(if different from location)
State tol Code
City/Town —
FI-‘A-GIA IA Qe Telephone umber
_ B. Pumping Record ��b�
-1-u).1 - 6 02. Quantity Pumped: Gallons
1. Date of Pumping Date
Tight Tank E] Grease Trap
3. Component: ID Cesspool(s) /. Septic Tank ❑ Ti g
j -- 1'n, 121(7. --
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No
If yes, was it cleaned? ❑ Yeo
' 5. Observed condition of component pumped:
6. rem em P mped By:
V.�� Vehicle License Number
,, e✓/ ,...51 VV 1 /[
Company
7. Locatio where contents were disposed:
_______
Signature of Hauler Date _
Signature of Receiving Facility(or attach facility receipt)
Date
System Pumping Record•Page 1 of 1
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