421 Pump Report 202094 Commonweal of Massachuseits
City/Town bf
SysteMP no Record.
Form 4.
DEP has provided this formi for use by local Boards of Health. Cghei fohns mafr. be used, but the
Information must be substantially the sialne as. that provided hem. 5ebre 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 15.35.1.
I
Important
When Ming out
forma on The
rr. use
Zb
0jpth a key
to mow your,
amr'- do not
use the return
key.
A. Facility Infomiation
1. System Location:
Address;
2.
3,
aty/Town state zip CO&
cwrrown I
rumpingmecorp.
Qate.cf.Pumpingate Quantity Pumped:ed:
D
Type'of -system: ff] Cesspool(s) 171 SopticTank ❑ Tight Tank
capons
Grease Trap
❑ Other. (describe):
4. Effluent Teo Filter present? ❑ Yes No If yes, was It clearied? .171 ye!j240
5. Condition. of System:
B. System Pumped BY.'
_iv ollk VaNde Lloanse Number
7. Location where contents were disposed:
swnJre of kaul er. Date
SIgnatura of ReceMng Fadflty Date
ftrm4.doc 03/08 System Pumping Record.- Page 7 of 1