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Wyk
Commonwealth of hil(*laelusetts
City/Town of
System Pumping Record
Form 4
R :C
IVED
0 1
TOWN OF NUK:o H ANDOVER
HEALTH DEPART ENT
DEP has provided this form for use by local Boards of Heelth. 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:
(>fdd
7(,/
d s
Ft?) "el
C /T
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
n9
State Zip Code
EJ
Da
Cesspool(s)
0 Other (describe):
State
Zip Code
Telephone Number
2. Quantity Pumped:
034eptic Tank
El Tight Tank Ej Grease Trap
4. Effluent Tee Filter present? Ej Yes 0 No
5. Observed condition of component pumped:
6. Systen Pumped By:
Company
7. Location where contents were disposed:
Signs of Hauler
lity (or a
If yes, was it cleaned? El Yes 0 No
Vehicle License Number
Date
fadlitY r6celPi) , - Date
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