HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 85 WINDKIST FARM ROAD 5/20/2025 4` Commonwealth of Massachusetts TO ppt�l
j - ncaVer
oven of
f' SySteM PUMPir`lg RecorCj MAY
Form 4 � a ����
DEP has, provlrir d this form Iof use, by for al Rorif(i�s rai' Fit�yallh. (_7Ct��er f� � y b �. �i )of►the
information rnu t or, ubstanfially the same as (h�nt pine.>virinr,9 i7 rr Before using Ihls ��'�ei eMt11 you(
local Board of Health to determine fhe form lhey tjse Sy`~Ipfn Purnping Record rr"lt_Jst W suturllttod to
the local Board of Health or other approving aulho(ily within 1,1 nays frorn the purnping date to
accordance with 310 CMR 15.351 __..__... __...
HOU5f front back �riEr rea r_5Ct rit'hT
A. Facility Information BIJII.DING front back side feai left riNht
mportant; When DCC.K „ir1(:1r'r
tllling out forrns 1. Systern Location .^
on the cornpulor,
rise only the lab (V?el,
key(o move, your Art eMs
cursor -do not /� ( ��+
use the return ____ C i( !"j"�—_—__---- -----_.._.. _....____. ._.__.__... r\AA -- _____.._..._ ._ ��_. .__-----
key. Cifyffown al Code
_._ 2. Sys em Owner.
rtr�rn��J yy-
Andress(If differom from location)
MA
Y Slule> lip code
Telephrne fVurnber
E3. Pumping Record
1. Date of Pura in f `"L __.__
P 5�31n - 2 Quantity f'urnpeU:
Gallons
1 Component: ( ) cesspool(s) Septic "lank (—) right Tank ❑ Grease Trap
(_..] Ofher (describe}); ._ _ .. _ _.__.._. _.._....._
4. Effluent Tee Filter present? Ye:, � N0 If yes, was it cleaned? C] Yes fvlc,
5. Observed condition c)ff cornpooent pur-nped:
6. System Pumped By:
Gave They
Mass1 Aj, p6 ass 1AD31 _
Name Vehlclr, l.icr.>nse Ni k, bE;r
2 P C e S o n P-nferprisos.._�._n�._ _
Company
T Wion Yyh(.ro wn(Cnts were dispost;d
G l _.------ _ __..._
Slgntllur(l of Hauler L;)sle
Slgrralutr Or fiecelving f-acdlCy (or at-fact) facility rr,;cr3ipl)
Mort-M,doc- 11112 `3y;(crn f ofnpinq