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
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