551 pumping report f/ Praj
Commonwealth of Massachusetts
City/Town of V I11 A lia p
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 lord Board of Health or other approving authority within 14 days from the pumping date In _
accordance with 310 CMR 15.351.
A. Facility Information
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tonna o01out System Location:
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use the returnCity/rown Stat Zip Code
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keY. 2. System Owner.
Name. 531 YWize Nce OM//
Address indifferent torn beim,)
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6121?N c( Tdeprore wren
B. Pumping Record -
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A. Date.of Pumping OCI `� - `r ,2. Quantity Pumped: Galan
- 3. Type.cif-system: In Cesspool(s) f-I�Saptic Tank 0 Tight Tank 0 Grease Trap
❑ Over(describe): /�
4. Effluent Tee Filter present? ❑ Yes o If yes,was N cleaned? .❑ Yes Jd'No
- 5, Condition of System:G4\OC)
B. ;gimped By.
) /x L5 Slit
lre W O/loth`' Vs**License Number '
7. Location where contents were disposed: f
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Signature of Hauler. Date
Signature of Receiving Fadlhy Data
ttrm4.doc 03/08 _ System Pumping Record Page 1 of I