System Pumping Records (002) Comrnonweaitn of Massa clIph'u,set.s
' 'CTVTown� of
A.
System Pumping Rec�ord
0.11'rn 4
DEP has provided this form for use by local Boards 04 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
3 local Board Of Health to determine the forn-,; they ' The System Pumping Record must be submitted to
the local Boar use. te
C of Health or other approving authority within 14 days from the Pumping date in
accordance%Aji-gh 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
use the return
.f.
City/Town .......... MA
key.
State Zip 70
Code
2. System Owner:
Name
-Kd rejs7-�j-&�.er;j�t-
M
-Zip Code —
Telephone Number
E- PUMPing RGCOrd
1. Date of Pumping
2. Quantity Pumped:ped:
3. Component: Date Ey m. Gallons
E] cesspooi(s) Septic T Tight Tank ❑ Grease Trap
TO Other(describe):
4. Effluent Tee Filter Present? j yes fNjo
If yes, was it cleaned? ❑ Yes No
5. Observed condition Of component Pumped:
<
t
G. System Pumped By:
---
vase a2
-VVind R,�;ver-Er�,.-vironrnen.tal----,--,, -Tei�icle License Number
0-ompany
7, Location Where contents were disposed: Uvdllrill VVVV TP
__j0_SPorterSt
Date
Signature of ce c -facility receipt)
Date
t5form4.coc.
System Pumping Record-Page 1 of 1