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4 Hilton St. system pumping record 12-23-19 .'� Commonwealth of Massachusetts City/Town of �IC-r-� System Pumping Record Form 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 tilling out forms 1. System Location: on the computer, / use only the tab _E T t f - ai _ key to move your Address cursor•do not �� use the return key. Cityffown State Zip Code 2. System Owner- -0 C- ram v �r�a cs Name Address(if different from location) City/Town State 7 8 S f S-Zip©de, ! _ Telephone Number B. Pumping Record 1 �'t`3 . +� f moo 1. Date of Pumping L Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ,B�eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yesa'No If yes,was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: 6. System Pumped By: Name vehicle License Number Company 7 Location where contents were disposed: Naverhill VjW i P 40 S Porter St Signature of Hauler Date or , +,.Aa 01835 Signature of Receiving Facility(or attach facility receipt) Date ^7" -2-38G t5form4.doc•11112 System Pumping Record•Page 1 of 1