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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 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
fining out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
City/Town State Zip Code
key.
VIr`o 2. System Owner:
v l rn Ca kueRL cC(ATL`t _
P � Name
ima No, \mp4,,,
Address(if different from location)
City/Town
4es
A �7 Y(Jf°P4i de
\--MS Telephone Number � �f
B. Pumping Record
- Go
1. Date of Pumpingpa 2. Quantity Pumped: Gallon
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank rease Trap
❑ Other(describe): ---
4. Effluent Tee Filter present? ❑ Yesva-Clo If yes,was it cleaned? ❑ Yeo
5. Observed condition of component pumped:
6. Systemgumped By:
. t le ® /� Vehicle License Number
o pany
7. Location
here contents were disposed:
!,(1 1\1 -- '
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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