67 Pump Report 2019 Commonwealth 1of chuseft
City/Tt311 n of• t 6 f e-�t ,`'' ;
System .Pi p-In'g:Record
Forth'4 s .
DEP has provided this form for use byioci>al Boards of Health,Otbef fohns may be used,but the
Information must be substantially the same ass 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
Ulfiortant-
n til nli g out 1. 'System Location: • `c
farms on the' -
computer,use
only the tab key Address
to move your.
cureor=do not coy/.own State, Zip Code
use the return
key. 2. System Owner. :.
Name.
Address•(if dtffererd from location)
cilyrrown State Zip.Code-
�.-- x756 -`aSG�,• •
Telephone Number
B: Pumping Record
.1. 'D,ateof•Pumping - Quantity Pumped: Gallons Irl
3.. Type.of system: ❑ •Cesspoot(s) Septic Tank GCl
Tight Tank ❑ Grease
Other.(describe):
4.• Effluent Tee Fitter present? ❑ Yes,' No if yes,was it ciearied? .❑ Yesa No
5. Condition.of System: _ , _
- --
6 Syste ) mped By:
VeWde ucense Number
any .
7. Location where contents Niers disposed: ,
Sigi,gEure of Hauler Date
Signature of Receiving Faaft Date
ffomAdoo-'Owe *em Pumping Record o Page 9 a.t