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4 Adi
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
on the
out forms 1. System Locatio 1q0
on the computer,
use only the tab
key to move your Ad re I ))
cursor-do not �1� -� Ma
use the return City/Town State Zip Code
key.
VQ 2. System Owner:
Name
renes
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record ,
2
1. Date of Pumping Date . Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pu7"d By:
Name Vehicle License Number
Stewart's Septic Service
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 aci Date
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