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t5form4.doc• 06/03
Form 4
Commonwealth of Massachusetts
City/Town of
Syste Pumping ec*
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.
A. Facility Informatio
1. System Location:
Address
City/Town
2. System Owner:
umping Record
1. Date of Pumping
State
AUG 0-7 ?017
OWN OF NORTH
EALTH DEPARTMENT
Zip Code
Zip Code
(— 7 7/ — o2S -
Telephone Number
State
tJato------ 2. Quantity Pumped:
3. Type of system: J Cesspool(s) El Septic Tank 0 Tight Tank
?LA nip c ber
Other (describe):
)
Gallons
4. Effluent Tee Filter present? ED Yes tr No If yes, was it cleaned? IJ Yes El No
5. Condition of System:
600
System Pumped By:
Name
.340 rc&C2C k3 3pM
Company
7. Location where contents were disposed:
Ls
6(o V(
Signature of auler
Vehicle License Number
Date
System Pumping Record Page 1 of 1