HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 WINDKIST FARM ROAD 11/28/2022 t4ECEivED
Commonwealth of Massachusetts Nov 2g 2022
N City/Town of �ANppvE
a System Pumping Record �,' ,7vyC�ARTnnENj
Form 4
N
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.
HOUSE: fipl�'v back side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, ((�
use only the tab � �h•1_CA
key to move your Address
cursor-do not i/,
use the return City/Town State Zip Code
key.
2. System Owner:
V`Rr� Joahn ) Cc�
Name
ream
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) .-ET-Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - --- - ---- -
4. Effluent Tee Filter present? ❑ Yes,,ErNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S
Signature o auier Dat
Signature of Receiving Facility(or attach facility receipt) Date
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