HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 85 WINDKIST FARM ROAD 8/13/2024 Commonwealth of Massachusetts
Clty/Town of
_ System Pumping Record � %tio`L�
Form 4 1
0 .
DEP has provided this form for use by local Boards of Health. Other forms may be �O the' ��
information must be substantially the same as that provided here. Before usin9,.{ s �(ii, check with your
local Board of Health to determine the form they use, The System PumpipgR. rd must be submitted to
the local Board of Health or other approving authority within 14 days from -he pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back side rear eft right
A. Facility Information BUILDING: front back 51 a rear left right
Important:when DECK: under
filling out forms 1. System Location: _
on the computer,
use only the tab
key to move your Address (�
cursor-do not `, ���� MA Q�6 L( -
use the return City/Town key. State Zip Code
n
2. System Owner:
S ) Jsw+
Name
man
Address(if different from location)
MA
City/Town State Zip Code
c� 1� ���-3��S.
Telephone Number
B. Pumping Record
1. Date of Pumping 2 2. Quantity Pumped:
Date 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:
d ct�
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31Z
Name Vehicle License Num r
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
GLS I
d -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
f
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