HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 120 WINDKIST FARM ROAD 12/11/2024 Commonwealth f Massachusetts
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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 same as that provided here. Before using this f0rm, 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 310CK8R 15.351
HOUSE: front
side rear ae right.
A. Facility Information BUILDING: front back side rear {eft right
DECK: Linder
Important:When
filling out forms 1� System Location:
on the computer,
use only the tab
keVto move your *udmuu
vumor-donnt MA
use the return
key. City/Town_ State Z' Code_
3. System
ame
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping -bate2� Quantity Pumped'.
Gallons
3. Component: F71 Cesspool(s) Septic Tank Tight Tank Grease Trap
0 Other (describe):
4. Effluent Tee Filter present? Yes No U yes, was itcleaned? 4Yes Fl No
5. Observed cond�iti'
8. System Pumped By�
Dave Tin Mass 1/A95
Name vcn/o`= ucenoo urnber
Bate Bateson Enterprises, Inc. ~---------
7. tion wherecontents were disposed:
LSD
-§7fg-nature of Receiving,Facility(or attach facility receipt) Date
t5fom4doc- 11/12 aysuem Pumping Record'PuWe1o/1