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/~om00QnVVeaKh of Massachusetts
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City/Town ��/ ,��� �\�wover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may beuoed but the
information must besubatanUaUythe same asthat provided here. Before using this form,—` check with your
local Board of Health to determine the form they use. The System Pumping Record must bo submitted to (
the local Board of Health or other approving authority within 14 days from the pumping in
accordance vvith31OCK8R15.351. --
Important:When
filling out forms 1. System Lo
on the computer,
use only the tab rr
key m move your Address
vumor-unnot
No u�me��� M �
key. CityfTown Tta_te___ Zip Code
VQ 2. System Owner:
Name
Address(if different from location)
_�tate Zip—Code
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Pumping B. Record |
` .'°\
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1. Date ofPumping 2� Ouan�v Pumpad� ^� °'-
Gallons
` 3 Type ofsystem: F7 Cesspool(s) Septic Tank [l Tight Tank [l Grease Trap
LJ
Other(describe):
4. Effluent Tee Filter present? Ej Yes F-1 No If yes, was itcleaned? El Yes F� No
5. Condition of :
6�co
G. |
Narftel— Vehicle License Number
'
-
Company/
7. Location where contents were disposed: /
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
°
' Signature of Receiving Facility ~~~
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System Pumping Record`page 1 of