HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 WINDKIST FARM ROAD 3/10/2023 �EGEIVEG
Commonwealth of Massachusetts ��Y�R 1C+ 2023
City/Town of ���NoovE�
_ \OwN OF OOIR k RTMEo I
System Pumping Record HEpCZN
Form 4
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: front back side rear le. right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. S stem Location.
on the computer, / /n�n,b 5 m
use only the tab (/(� /1/YJ J
key to move your Address
cursor-do not /1_Oe
use the return City/Town
key. State Zip Code
2. Sy e Owner:
ud
Name
nlmn {
Address(if different from location)
City/Town . State
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc ' where contents were disposed:
LSD
�0z
Signature of Ha Date
Signature of Receiving Facility(or attach facility receipt) Date
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