System Pumping Record (002) — omnio D -F, ith of a s se is
SYsterll Purnping Record
Form 4
DEP has provided this form for use by iota; Boards of Health. Other forms may be used, but the
Wormation roust 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 Boarcl of Health or other approving authority vvithin 14 days from the Pumping date in
accordance wi,l; 310 U-MIR 35.351.
A. Facflity_�
Information
important:Wher
filling cut forms 1. System Location:
the computer,
use
use only the tab f�)
key to move your Address ---------_._cursor--do not
MAuse the return
key. City/Towm _._....---------
State Zip Code
?. System Owner:
VQ On
----------------
Name _----_-_-_
ream l
kddress(if di`event€romp location) --------_—.---
U�;crown - - State - _ —
Zip Code
Telephone Number
B. Pumping Record _
1. Date of PumpingS - 7
Quantity Pumped: ji
iloni
3. Component: 1_7 Gesspool(s) Septic Tank ❑ Tight Tank
9 ❑ Grease Trap
€_ Other(describe):
4. Effluent Tee Filter t? ❑ Yes 1 „ ? ❑ `!es
es, was it cleaned? ❑ No
5. Observed o-ohd rion of cornponent Pumped:
5. System Pumped By:
Name ----- - ..._.._.
--.._ ..
-----—----- --
'Jehic€e License Number
Vvind River Environmental
w'om parry
?- i ocatio^ev ere contents were disposed.
Date _----�r
E M
Signature of Rece€wing i aci€iy(or attach facility receipt) Date_..._..__ _.
t5fonn4.roc•11/12
System Pumping Record•Page 1 of 1