HomeMy WebLinkAboutSeptic Pumping Slip - 56 Windkist Farm Road - Septic Pumping Slip - 56 WINDKIST FARM ROAD 10/11/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
.7 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 some as that provided hare. Wore using this form, ohook 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 16,351,
HOUSE: frog back side rear le on
A. Facility Information BUILDING: front back side rear left ri-gh
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 t 1 MA
use the return key. ChyCrown State Zip Code
'i
2, System Owner:
' Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping D ie ' 2. Quantity Pumped: 1
Gallons
3. Component: ❑ Cesspool(s) rA 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 TlneyMass 1AA95 Mass 1AD31Z
Name _ 1�hlcle Ltcens�vNumber
Bateson Enterprises, Inc.
Company
7. ,ation where contents were disposed:
(-G L S D7
lz�
Signature of Hauler Date
Signature of Receiving Facillty(or attach facility receipt) Date
E
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