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697 Pump Report 7-19-18 Commonwealth of Massachusetts ViaCity/Town of #1 i;skSystem Pumping RecorForm 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 filling out 1. System Location: forms on the computer,use only the tab key Address to move your _ cursor-tle not City/Town State Zip Code use the return key. 2. S Stam Owner: 4 L �Jomt\\A - - Name - - 69`) F� �zG cE 62.0 Address(if different from location) City/Town State / / ,21p Code - — r /\ 2 ttv\ Q( Telephone Number B. Pumping Record G C 1. Date of Pumping pale l� to — 2. Quantity Pumped 'Gallons - - 3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 3 cu r Y�L` 11W- 4. J 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes No 5. Conditionti� of System: �dR/ 6. System umped By: Name Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1