170-171 pumping record 2017 • l'( '',7? /;?- i '9. ,
• \_ Commonwea'th of N} ssachusett
a = City/Town of /JO l 'l/ CU
•
— - , System Pumping Record
� _ �� Form 4
• DEP has provided this form for use by ,oca' 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: .
in/her.tilling DJ; 1. System Location:
.Dmp,::e- ,.se
ac!y the tac key Address
—
!c rncve yc,_.
c:,'sor-do not
se the ett r� City/Town State Zip Code
key
: s,--R,6,4,.\3,-.) st
2. System Owner:
4
Name
a X, 170— t71 WEST HT1 f
j'"" "ti Address(if different from location)
Cityfrown Sate
) (( r (!� L// /� Zip Code
-_( ' 1 F ' `" Teleepphonne Number
B. Pumping Record .
1. Date of Pumping Dale 2. Quantity Pumped:
Gallons
3. Type of system: ill Cesspool(s)/o ' . Septic Tank LT Tight Tank Q Grease Trap
Other (describe):�„ c ""'(sr �'�� ocp ' ipc,
4 Effluent Tee Filter present? _; Yes/G-No " If yes,was it cleaned? 7 Yes YI No
5. Condition of System:
6. }System �mped By.
kw.0 /k_ �0,///�,�f�i. Vehicle License Number •
par,y /l fs '/l
7. Location ere contents were disposed:
y11s65
•
•
i Signature of Hauler Date
Signature of Rece'ving Facility Cats
t5form4.doc•03106 ` 1
1 1-1` � /1 \(\ C,6c /► k \-1 System Pumping Record•Page 1 of 1