23 Oakview Ave. system pumping record 11-26-19 Commonwealth o
ftAassachusetts
City/Town ofv+,
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other r'orms 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 _
key to move your Address
cursor-do not
use the return
key. Cityfrown Slate Zip Code
2. System Owner:
Lxv�-,rra.,
Name -
a�
Address(if different from location)
City/Town State Zip Code
7z—
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool($) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Observe, d condition of component pumped:
6. System P ed !
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date r
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