HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 WINDKIST FARM ROAD 10/31/2025 °fin r�rn over
Commonwealth of Massachusetts
r City/Town of OCT
System 025
S y Pumping Record
Form 4 ea/
DEP has provided this form for use by local Boards of Health. Other forms may be Wised, uutt 9 P- t
information must be substantivally the same as that provided here. Before using this form, check with your
local Board of Health to determine the forrn 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 313 CMR 15,351. -
______._______ HOUSE: fro back side rear rig hi
A. Facility information BUILDING: front back side rear- left right
Important:When CHECK: under
filling out forms 1. SyStenn Loc-ation:
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the. return __...__. - . ._.._._ ...__. _....__------
key, ._____--
CityrT-own State Zip Code
2. Systern Own r:
- ... ._._. 1W(..-_ � L _.----
— p Name
Address (if different from location)
MA
_.
City(Towrr State � � ,may Zip���e,
Trylephorre Number
B. Pumping Record
1. Date of Pumping E °� 2. Quantity Purnped
Uaie � Gallons
3. Component: �-] Cesspool(s) ['Septic Tank ❑ Tight Tank ❑ Grease Trap
(� Other (describe}: _.._......_ _....... . ...... . .. _..__
4. Effluent Tee Filter present? ❑ Yes [ Now If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pur > d:
6. ystem Pumped By
( ave T'In ----._ __. -MassMSs._1.AD31Z
_ ,
I\r me Vehicle license Number
Bateson Enterprises, Inc.
Crrrr7tlany
`l. L..o lion w ere contents were disposed
Signature of Hauler D@te
Signature of Receiving Facility(or attach facility re,ceiot) hate
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