System Pumping Records (need to be separated by address) (009) Commonwealth of Massachusetts
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City/Town of 154-4 1&
System Pumping Record
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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 wish 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, 41z
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
VQ 2. System Owner:
V-'�'
Name
euen
Address(if different from location)
City/Town State Zip Code
Cf V —
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gailons
3. Component: F-1 Cesspool(s) Septic Tank 0 Tight Tank ❑ Grease Trap
Other(describe):
4. Effluent Tee Filter present? 17 Yes ^ No If yes, was it cleaned? El Yes [I No
5. Observed condition of component pumped:
6. System Pumped By:
q 71 Z I
Name Vehicle License Number
-Wind River Environmental
Company
7. Location where contents were disposed: I.W.W.T.P,
JPSW'fC'V
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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