System Pumping Records (need to be separated by address) (004) Commonwealth of Massachusetts
--- W City/Town of /&m
System Pumping Record
Formal 4
:DEP 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:When
filling out forms 1. System Location:
on the computer,
use only the tab _ � - --
key to move your Address - --
cursor-do not S� MA
use the return - ---.--- _
key. City/Town — — State Zip Code
2. System Owner:
CAS- P- l ----- -
Name --
rerun '>
Address(if different from location) --
City/Town State Zip Code
9- _ s �
Telephone Number
B. Pumping Record
1. Date of Pumping pa _� L —_ 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g El 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 --- ---------
?. Location where contents were disposed:
r,
Signature of Hauler Dats -----
Signature of Receiving Facility(or attach facility receipt) gate
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