HomeMy WebLinkAboutSeptic Pumping Slip - 80 Windkist Farm Rd - 11/25/2024 - Septic Pumping Slip - 80 WINDKIST FARM ROAD 11/25/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
OEP has provided this form for use by |Ooa/ Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this h)rm, check with your
local Board of Health to determine the form they use. The Syabarn Pumping Record must basubmitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310CK0R 15.351 HOUSE: qSEnt ack side rear(Deft right
A. Facility Information BUILDING: back side rear left right
|mpnnm DECK: undera Important: �
filling out forms 1. System Location-,
o"the computer, \
use only the tab
key to move your Address
oueu,-uono, MA c>y�-([\
use the return
may, ~'y''``'^ State ''p C"=
2. System Ow
Name
Address(if dIfferent from location)
MA
QtynmwnZip Code
rN
GG
Telephone'Number
B. Pumping Record
1. Date of Pumping (Date 2. Quantity Pumped: I o ns
3, Component: F7 Cesspool(s) Septic Tank 7 Tight Tank Grease Trap
Fl Other (describe):
4. Effluent Tee Filter present? E] Ye No If yes, was it cleaned? D Yes El No
5 Observed
8. System Pumped By:
Dave Tlpey Mass 1/A95E
Name Vehicle License
.Bate E te[ i Company
7.t-ttt%fion wheredisposed:
GLS
_�=ign XCure -Date
Date
t5fonn4dmc' 11U2 System Pumping Record ^poga1 of
`