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