Loading...
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 ± 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 . t5form4.doo•03/06 System Pumping Record•Page 1 of 1