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# City/Town of r N6r`f�l' ^
-�'- �; System Pumping Record
' 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 fcrm they use. The System Pumping Record must be submitted to
the loca' Board of Health or othe-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 Locat:oi:
'arms on the
computer. Lse
crly the tab key Acdress —_
to!Hove your
cursor-da rct
use the return Cityrown Stare Zip Code
key.
2. Syste Owner:
I ' l K°S5 6 N t )46A.
1,er
arse'
3 Y- eaq3 Ya ‘ 11)1
"" Address(if different from location)
•
City/TownSate ��V Zi
gF ,1ittnt'
e ^umber
B. Pumping Record , 13 I7 / �``
1 Date of Pumping e 2. Quart:ty Pumped. l " vU —.
Dat
Gallons
3. Type of system: 7 Cesspool(s) Septic Tank 7 Tight Tank
❑ Grease Trac
Other(describe):
4. Effluent Tee Filter presenf? ❑ Yes No If yes, was it cleaned? ❑ Yes 7 No
5. Condition of System:
GO 60
6. System Pumped By:
\v` 6l S61JZ _----
ame �-sS1/C Vehicle License Number
Gl" .
Company
7. Location where contents were disposed:
S.giaire of Hauler
Da:e
•
Signature of Receiving Facility Cate
t5form4.coc•03/06 1-70'139) V
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