132 Pump Report 10-30-17 o!U/U• ,o2U-Ici
Commonwealth of Masss chusetts
fg_ anl_F City/Town of Am h tCSt
iL? 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
ony the tab key Address "--
to move your
cursor-do not
City/Town
use the return b State Zip Code
key. 2. t$yste weer.
w t rftyzo�
�j
�X "led\ UTQsr FAR -5 OW9
Address(if different from location)
City/Town State Zip Code
F1-6F1-6R-NCE Telephone Number
B. Pumping Record
1. Date of Pumping �'L� 17 2. Quanti Pum ed: 66 C4
Date - ry p Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank IE Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? 9 Ye _S No
5. Condition of System:
(rte CV ,
r 6. ysterp,P,umped By:
a e ��� Vehicle License Number
RBCS sit wo(k� '
C mpany
7. Location ere contents were disposed:
NS
•
Signature of Hauler Date
Signature of Receiving Facility Date
•
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