HomeMy WebLinkAboutSeptic Pumping Slip - 171 LACONIA CIRCLE 6/22/2016 Commonwealth of Massachusetts
r Own of
YS
Form 4 1c.vW4�.,�
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 form, check with your
local Board of Health to determine the fora they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information,
1. System Location: Left/Right front of house, Left/ i ht rear of pause `Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right reair of building, Under deck
Address
City/Town State Zip Code
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2. System Owner.
wrc �r
Name'
Address(if different from location)
City/Town ' State p Code
t Telephone Number
. Pumping ecor
1. Date of Pumping 2. Quantity Pumped: Gallons
—T
3. Type of system: ® Cesspool(s) Septic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter resent?
p E] Yep " No If yes, was it cleaned? ® Yes ® No,
5. Condition of St m:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc•
Company
7. Locati n;-W are contents were disposed:
PL 3; Lowell Waste Water
Wal .
Sign a qj Haute Date I(
t5form4.doc-06/03 System Pumping Record•Page 1 of 1