SYSTEM PUMPING RECORD 6-28-19 %ommonweelth of Massachusetts
w .--- -- W City/Town of �
System Pumping Record
Form 4
OEP has provided this form for use by local 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
Important:Wher•
filling out forms 1. System Location:
on the computer,
use only the tab ____� __ (� r✓Fs _ __fi_
key to move your Address --
cursor-do not S
use the return "� -- — MA
key. Cityrowr, ----- — State Zip Code
VQ 2. System Owne
6: lxcc J✓re_
Name -- ----- --- — -- -
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ( Septic Tank ❑ Tank Tight g ❑ Grease Trap
❑! Other(describe): — ---- —
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 Vehicle License Number
Wind River Environmental
Company ---- -------------------
7. Location where contents were disoosed:
0
Signature of Haufer --- - Data ----- ---
Signature of Receiving facility(or attach facility receipt) Date —
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