281 Pump Report 11-20-17 G/WU- DpU-:s j
Commonwealth of Massachusetts
l .4, p City/Town of , 111
7V /41441
- i1,- a� 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:
Wnen filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not City/Town State Zip Code
use the return
pth-
key2. B es".tem O r. ,�./ 6,1&_) Al� ()
Ill NI 1 �ft '(
Name
NG 1 �114-n t V c 6 p •
Address(H different from location)
City/Town 2713.. A(Idt5 iRW4/Co4
8
Yl -olLbfc Telephone Number
B. Pumping Record •
7
.1. Date of Pumping �1e�- �� i 2. Quantity Pumped: I Feb
3. Type of system: E Cesspool(s) ,eptic Tank 0 Tight Tank ❑ Grease Trap
❑ Other(describe). l — QLnn(Lrlka1��7)1NVC'
V
4. Effluent Tee Filler present? ❑ Yes No If yes, was it cleaned? 0 Yes.2'No
5. Condition of System: I N
�uoo LI vh2S 1 \I (-6N� ill ,
6. System pumped By:
m o2 -
e
Vehicle License Number _?fit i:/ . `ILGkilpcan�A
C mpany
7. Location where contents were disposed:
C ? -
Signature of Hauler , Date
• Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Recocd•Page 1 of 1