5 CEDAR HILL ROAD SYSTEM PUMPING RECORD 12-9-19 Commonwealth of Massachusetts
==fir City/Town of IC-1^�
System Pumping Record
_ Form 4 p 9
UEP has provides this form for use by local Boards of Health. Other torms 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: 1
on the computer, f--1
5 E V !]
use only the tab _ �f
key to move your Address
cursor-do not Q i q "7 G
use the return key. City/Town State Zip Code
2. System Owner:
r- pe(- P G1-d Day�6
Name -- - - --
relnr
Address(if different from location)
Cityffown State Zip Coded9
Telephonember�
B. Pumping Record
1. Date of Pumping I 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Fitter present? Yes No If yes,was it cleaned? 2-1f es ❑ No
5. Observed condition of component pumped:
a
6. System Pumped By-
'r"[ -�9 0
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date W.35 In:
w�
Signature of Receiving Facility(or attach facility receipt) Date
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