System pumping record 3-23-20 Commonwealth of Massachusetts
City/Town ofZ6LL I Y�
System Pumping ecord
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 CM 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the ,.y g
computer,use
only the tab key AtWles
to move your , ' f
cursor- not no CitylTown State Zi Code
use the retet urn p
key. 2_ Systeq Owner:
dL
Name
Address([f different tram location)
CitylTown state Zip Code
Telephone Number
B. Pumping Record i`��
1. Date of Pumping �/a � 2. Quantity Pumped: '��V
Date Gallons
3. Type of system: ❑ Cesspool(s) XSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sys em Pumped By:
e Vehicle License Number
company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc-03106 System Pumping Record-Page 1 of 1