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• Commonwealth pf Nitr 330LISettS
City/Town of )ctevol
System Pumping Record
Form 4
E C 1
JAN f)• 011'
TO 'N OF NO l'fl."1-11 AND(,)VER
HEAL:11-1 DEPARTMENT
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
1. System Location:
'767
Add
6:1' 4/ ei
elra/-12--1
City/Town
2. System Owner:
k: (-
Name
State
Zip Code
Address (H different from location)
City/Town
Pumping Record
State
Telephone Number
1. Date of Pumping
Gate
6 ,s-c.:(,/
Gallons
3. Component: Cesspool(s) ErSeptic Tank El Tight Tank El Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes ED No If yes, was it cleaned? 0 Yes 0 No
5. Observed condition of component pumped:
2. Quantity Pumped:
6. System Pumped By:
jlorJ p\,111,7y,c)
Company
7. Location where contents were disposed:
of R vl (or attath fadilty r lot)
Vehicle License Number
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1