HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 WINDKIST FARM ROAD 5/13/2024 �.ndoet
I-. L
Commonwealth of Massachusetts '
= City/Town of MAC 13 2024
o System Pumping Record
,r 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. —
HOUSE: front 6ack side rear(2)right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,use only the tab lSrN
key to move your A dres
cursor-do not ,c�, MA (31 F YS
use the return City/Town State Zip Code
key.
2. Syst m Owner:
Name
reran
Address(if different from location)
MA _
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping � � 2. Quantity Pumped: Gal ons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter presen/pponent
Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condi 'on of co pumped:
t)_
6. System Pumped By:
Dave Tiney _Mass 1 AA95 Mass 1 AD31 Z
Name Vehicle Licens umber
Bateson Enterprises, Inc.
Company
7. �fiion where contents were disposed:
�� Z
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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