10 WHITE STREET SYSTEM PUMPING RECORD 8-30-19 - OTHER Commonwealth of Massachusetts
City/Town of `� (cwe
System Pumping Record
y` Form 4
DEP has provided this form for use by local Hoards 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 rTT—
key to move your address
cursor-do not 5� MA Q r
use the return City/Town State Zip Code
key.
2. System Owner:
'lc?
Name
Address(if different from location)
City/Town State lip Code
�7
Telephone Number
B. Grumping Record
1. Date of Pumping D � 2ate . Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
PL
Other(describe):
4. Effluen-Tee Filter present:? ❑ Yes 0q .No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
- g 6 Z-5
Name Vehicle License Number
Wind River Environmental
Company
7. Location where contents were dlsijosed:
4�
Signature of Hauler Date
•
Signature of Receiving Facility(or attach facility receipt) Date
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