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115 Pump Report 2020�L\ Commonweaq— A Massac usetts 9Ui City/Town ofSystem Puping Record J Form 4 Kl,mo/ DEP has provided this form for use by Boards of Health. Other forms may be used, but the information must be substantially the same 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 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 1. System Location: A , / Address ) � /l Zi7� ),U IV City/Town -- --- - B. Pumping 3. Component: ❑ Other (describe): MASS State 2. Quantity Pumped Zip Code Two Compartment Tank 4. Effluent Tee Filter Present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped 6. System Pumped By: Name / CLEAN SEPTICS, INC. Company 7. Location where contents were disposed: BONDI'S ISLAND, INDIAN ORCHARD, MASSACHUSETTS Signature of Hauler ,l ig tune of receiving Facility (or attached facility receipt) OWN COPY YELLOW/SILVER MACK "\ i / X / Customer # Invoice # System Pumping Record • Page 2