75 Pump Report 2019 Commonwe Ith OassAchus is
Ci /Town ®f
system •PU In•g 'Record.
Form 4
i DEP has provided this form for use by'local Boards of Health. Other foams may be used,but the
information must b6 substantially the same asthat 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 3110 CMR 15.351.
4 .
A. Facility InfOlf'fll7ation
Important,
When filling out 1. System Location: � .• . " �`'
iorms_onthe' --
computer,use
only the tab key Address
to move your.
cursor=do not C[ty/rown State I Zip Code r"
use the retum
key. 2. System Owhe�.
. Name
.ddress•(9 different from location)
Cityltbwn ' - .. State Zip.Code <
5�-1� bL�
Telephone Number
Bo Pumping Record
A. 'D•ate.of Pumping Date 2. Quantity Pumped: . Gallons
3,_ Type,of•system: ❑ -Cesspool(s) Septic Tank' ❑ Tight Tank ❑ Grease Trap
❑ Other.(describe): —
4. Effluent Tee Fiiter.present?)!�Yes•�3` No if yes,was it cleaned? Yes•D ,qo
5. Condition,of System: `
6. Syste Pumped By:'
a e 1 - Vehicle License Number ,
C any
7. mLocation where conterits'were disposed:
&igi►ftre of Hailer.
Date
Signature of Receiving Facility Date
WormCdoo^03/06 ' System Pumping Record-Page 1 of 1