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System Pumping Record
Form, 4
DEP has, provided this forma for use by local Boards of Health. Olther forms may be used, but the
information must be substantially the same as that provided here. Before using this fora, check with your
local Board of Health altih etermin the form they use. The System Pumping ;Record must be submitted t
the local Board He alth or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351& 1
A. Facimlity Information
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Important:When
filling out formIs 1. System Location:
on the computer, 31
use only the tad "I'll11.11,11'll""II-1.11.111,111-1111,"-.,lI...111111-1- �'�j '-.sr
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key to move your Address
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I City/Town State ZipCode
VQ2. System wrier
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A,ddress(if different from location)
City/Town State Zip,Code
Telephone Number
m.,
B. Pumping Record
1. Date of Pumping Date x...� ����. ... 2. Quantity Pumped:
3. Co Cesspool(s) Septic Tank El Tight Tank 0 Grease Trap
Other( es ri
4. Effluent Tee Filter present El Yes If yes, was it cleaned?" Yes 0 No
5�. Observed condition of cow onent a r
6. System Pumped By.
Name Vehicle License Number
Stewart's Septic 58 So. Kimball St., Bradford,MA
Company
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7. Location where contents were disposed
20, So., M1II St. Bradford, A
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�IDate
Signature elllFacility �r attach facility receipt), Ilt
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