System pumping record 3-24-20 -
Commonwealth of Massachusetts
City/Town of
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 filling out 1. System Location:
forms on the f
computer,use
only the tab key r�ss ry�
cursor move your �.� R U
usethe ret ret urn not RA
State Zip CitylT Code
use t
key. 2. Systep Owner:
7 )OM6LL 61 n
Name
Address(rf differentfram location]
CitylTown State Zip Code
Telephone Number
B. Pumping Record f !1
1. Date of Pumping � r ��2. Quantity Pumped:
Date / y p Gallons
3. Type of system: ❑ Cesspool(s) i '.Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): 7
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.
Name y Vehicle License!Number
l
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
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