HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 WINDSOR LANE 3/23/2026 Commonwealth �� K�Massachusetts
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System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must bo substantially the same as that provided here. Before using this form, 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 ur other approving authority within 14 days from the pumping date in
accordance with 31UCyWR16.351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 72 Windsor Lane
key m move your Address
oumv,-do not
North MA O1845-563S
ueo\honoturn —
key.
~'^r'~`~' �`"`= "tip Code
2. System Owner:
~---� Adam Davies
am e
State Zip Code
978-484-9078
Telephone Number
B. Pumping Record
1. Date ofPumping 3/23/2028 2. Quantity Pumped: 1500
3. Type ofsystem: Cesspool(s) Septic Tank Tight Tank Grease Trap
0 Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? Yea Z No
5. Condition ofSystem:
Good, iproperly
G. System Pumped By:
Jason Elliott �71437orV85��7
Name Vehicle License Number
|w*ater and Elliott Services LLC-DBAJason
Elliott Pum i
7. Location where contents were disposed:
GLSD