HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 WINDKIST FARM ROAD 6/17/2020 Commonwealth of Massachusetts
RECE�vVID
City/Town ofi / �r� a
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System PumpingRecord o�N° 'MS%j
Form 4 ord �o EQPR
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
filling out forms 1. System Location.-
on the computer,
use only the tab IvT
key to move your Address ��—
cursor-do not
use the return
key. UtyrT own j�� . K-; y J
� 2. System Owner: state Zip Code
Name
nrun
Address(if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping $ la> 2'�% —�1
Date 2. Quantity Pumped: zJ y✓
3. Component: Gallons
❑ Cesspool(s) ,Septic Tank
❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes, } No
If yes, was it cleaned? El Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Name �`� t c T i
�G 7C)
Service Pumping&Drain Co, Vehicle License Number
Company ll rk
North Reading,Kk 01864
7. Location where contents were disposed G~
J'i
SignalL46W Ha�e
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11112
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