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DEP has provided this form for use by local Boards ofHealth. {}thA be used, but the
information must ba substantially the same as that provided here. Before �� with your
local Board of Health to determine the form they use. The System Pumping Reoord ubmitted to
the local Board of Health pr other approving authority within 14 days from the pumping date in
accordance with 310CMR 15,351
A. Facility Information BUILDING: front back side rear-\eft right
DECK: under
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filling out forms 1.
on the computer, yStem
use only the tab
key m move your no�
cursor'uonot MA
use the return
key. City[Town�� '�
— --
Code
2. Sys em Owne
AL
N me
Address(if different from location)
K8A
Qty(Tv=n State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: F7 Cesspool(s) WrSepdo Tank 7 Tight Tank 7 Grease Trap
[� Other (describe):
4. Effluent Tee Filter present? 7 Yee No If yes, was it cleaned? 7 Yea No
5. Observed condition of componentp U
G System Pumped B
Vehicle License Number
B
Company
7. L tiondisposed:
TIL�S D
Signature of Hauler Date
_�_i_gnature of k—er-eivIng'Fac—ility—(or 'Date
t5fom4.doo1182 System Pumping Record 'Page 1 of