Loading...
972 System Pumping Report 6-23-20Commonwealth of Massachusetfs City/Town of System :Piuniping Racbrd Fornli 4. . DEP has provided this form far use by local Boards of Health. Oilier fotms may be used, but the Information must be substantially the s?me 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 submifted to the local Board of Health or other approving authority within 14 days !tom the pumping date in . accordance with 310 CMR 95.351. A.. Facitity Inforfriation .. Importarcb., vNtenflflingbut 1, System Location: ibtns an the' computer, use only the tab key . to move your cursarL do not use the tetum 'W a. Address Wfrown Sfete ztp Code . CNyfrown state S. Pumping Record 4. Date.of,Pumping Date 2. Quantity Pumped:. Gallons 3._. Type:of•eystem: ' ❑ Cessppol(a) pticTank ❑ TightTank ❑ GreasaTrap ❑ Other. (describe): els 4. Effluent Tea Filter present? ❑ YesNo If yes, was R cleaned? ❑ Yes No 5. Condition. of System: e 6, System Pumped By: NameILicense Number iDlg 7. Location where contents were disposed: 81gh#hve of ter Data q . �pignatutp of Receiving PaciINy Data 00=4.doa 03106 - System pumping Record - Page 1 of 1