3 CEDAR HILL ROAD SYSTEM PUMPING RECORD 8-29-19 C.'ommOn wealth ®f Massechuset-s
City/Town Of ,i
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 CM 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only th-e tab _ ' �6y$ -------—--- —— --
key to move your Address
cursor-do not
use the return -- $ F`-- ---- ---- —
key. Cityfrown State Zip Code
2. System Owner:
,%,I or ,ie I
Name -- ------ --
ream
Address(if different from location)
City/Town State Zip Code
Q17 A io
Telephone Number
B. Pumping Record
t ' xg
1. Date of:Pumping Date - - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) If Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other{describe): ---
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
wvillo
6. System Pumped By:
Name Vehicle License Number
Wind River Environmental
Company --- -----------
7. Location where contents were disposed:
4F Af
.
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.coc•11/12 System Pumping Record•Page 1 of 1