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1338 pumping record 2017 512 %' . Commonweal ■ .f M_schu_e is 7-1 # 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 V ChV‘\v' System Pumping Record•Page 1 of 1