579 Pump Report 11-7-17 of /U- ao :f,/.
i
I ' Commonwealth of Mass chusetts1
r� q, =-f-p. City/Town of rjIijs (N 6 ,111 40,1 •-+-67A
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Vii__ Z 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 tilling out 1. System Location:
forms on the
computer.use
only the tab key Address
to move your
arson-tlo not City/Town State Zip Code
use the return
kev. 2. System
ystem Owner:
411 pous S �n4)J4 ��
p,wr. o Names?9 F „^anon) V
Address(ti differentlfrom loloccation)
City/Town State 1,8//
( Zip Code
f t c Telephone Number 1- v
B. Pumping Record
.1. Date of Pumping Date 2. Quantity Pumped: canons
3. Type of system: ❑ Cesspool(s) Septic Tank C Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes '' No If yes,was it cleaned? C Yes o
5. Condition of System:
6. Sped By:
Vehicle License Number/gsIrt wVA.�
Csnowyy
7. Locatiohere contents were disposed:
Signature of Hauler Date
Signature of Receiving Fadlity Date .
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