System Pumping Records (003) All Commonwealth nfMassachusetts
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System Pumping Record
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must ba substantially the same as that provided here. Before using this form, check with your
local Board of Health ho determine the form they use. The System Pumping Record must ba submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 31OCK8R15.361
A. Facility Information
Important:When
filling out forms 1. System Location:
on the
key to move your Address
cursor-do not
use the return
—^.
City[Town State Zip Code
2. System Owner:
Name
61A Address(if different from location)
City/Town State Zip Code
_f�lephone Number
B. Pumping Record
1. Date ofPumping 2� Ouandy Quantity
DateGallons
3 Component: [] Cesspool(s) Septic Tank [l Tight Tank Grease Trap
E7 Other(describe):4- Effluent EfDuentTee Filter present? Fl Yea P7 No |f yes, was i1cleaned? L] Yee E] No
5 Observed condition of component pumped:
__ .............. _...........___-..........
______—__-_
& System Pumped By:
Name Vehicle License Number
7 Location where contents were disposed:
SignatureSignature of Hauler Date
-Facility. , receipt) --'
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