HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 WINDKIST FARM ROAD 11/27/2023 Commonwealth of Massachusetts
City/Town of 101
System Pumping Record
a 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: Qront
back side rear left right
A. Facility Information BUILDING: back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, —in
use only the tab
key to move your Add re s
cursor-do not IJ Ctsl ie� MA Q 1 U
use the return
key. City/Town State Zip Code
reb 2. System Owner: �w
�e ,�►1 � `4-0
Name
rerun
Address(if different from location)
_ MA
Citylrown State Zip Code
-�& 1- 8$ &-
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1� L3 2. Quantity Pumped. Gallons
3. Component: ❑ 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. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mas F5821 Mass_ 1AA95E_
Name Vehicl icens umber
Bateson Enterprises, Inc.
Company
7, tion where contents were disposed:
GLS
� Ibis - -
Signature ol Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date - — — -
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