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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
|ong| 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 31OCIVIR15351
A. Facility Information
Important;When ~�=
filling out forms 1. System Location:
onthe computer,
use only the tab `
key mmove your Address
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2. System
momo /
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date ofPunn 'ng2. Quantity Pumped:
DateGallons
3. Component Fl Cesspool(s) El Septic Tank F-1 Tight Tank Fj[E}reaseTrap
[] Other(describe): --
4. Effluent Tee Filter present? [I YesEl No |fyes, was |tcleaned? E] Yes E] No
5. Dbnomod ponditionofnompnnentpumpmd:
6.\ te PurmzpedBB
ame Vehicle License Number
�erts9 Se
Septic 58 So Kimball St Bradford Ma
Cc any
ocation where contents were disposed:
7ignature of a Date
-ignature of Receiving Facility(or attach facility receipt) Date
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