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46 Pump Report 6-8-18 • Commonwealthif Massachusetts City/Town of ii� imtimSystem Pumping cord 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 filling out forms 1. System Location: on the computer, use only the tah key to move your Address -- - - -- ----- --- cursor-do not --—� use the return Ci (Town —'— key. City/Town State - -- Zip Code i©I 2. System Owner: C- Q 0 rrLffi2 Name .» _�16 (+Dro m .D 1Address(If different from location) - - - City/Town State Zip Code Fitt%T p n�v CE • Telephone Number B. Pumping Record 1. Date of Pumping 3-00f. g' 2. Quantity Pumped: �� �) Dale Gallons 3. Component:p ❑ Cesspool(s) dElleptic Tank ❑ Tight Tank El Grease Trap 0 Other(describe): f` \I OS' - 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? 9 Yes No ( • 3 5. Observed condition of component pumped "-_D.. 6. System Pumped By: W�Y kJ.''�`(]]))r� t $ f{l C fl to ri ®i2 /y Vehicle License Number - o pany J 7. Location where contents were disposed: iN1 SQ — Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1