Untitled1352 Pump Report 2019 Commonwealth of MassachuseAts
City/Town of tc" --
System Pq i n•g�'R®yard
Foto•4 j
DEP has provided this form for use by'locai Boards of Health. Other fofms 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 Ithe pumping date in
accordance with 310 CMR 15.351.
: A. Facility Inforrhation
Imp
ortant
Wh n filling out 1. System i_ocation;
forms-on the'
computer,use
only the tab key Address
to move your.
cursor=do not Cfty/rown State Zip Code
use the return
key. 2. stem Owner:
Name,
�0 Addrpss•(If 4 ffierent from location)
Citylibwn awe '. p.Code
Telephone Number;
B. Punrtping Record
•1. 'D.ate.of Pumping Date 2. QuantityPumpGallonsGallons
3,• Type,of system: ❑ Cesspool(s) ptic Tank ❑ T ht Tank ❑ Grease Trap
❑ Other.(describe):
4. Effluent Tee Filter present? ❑ .Yes, o If yes,was it cleaned? .❑ Yes No
5. Condition.of system:
6. . a roped By: .
a e 1 � VehicleLirmnse Number
.C any . .
4.
7. Location where contents Were disposed:
Signdture•of Hauler. •• 4 Date -
3
Signature of Receiving Facility Date
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