HomeMy WebLinkAboutSeptic Pumping Slip - 85 LACONIA CIRCLE 9/6/2016 Common of Massachusetts Qµa 'llaru
City/Town of .
System Pumping.Records
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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 form 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 I Right front of douse, Left I Right rear of house, Left/r 9ht-Side4 house,)Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
` ,—
city/Town State Zip Code
2. System Owner.
Name`
Address(if different from location)
CitylTown State, Zip
Telephone Number
.B. Pumping !Record
1. Date of Pumping 2. Quantity Pumped:
Late Gallons
3. Type-of system: ❑ Cesspool(s) a_Sbptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑ N i" If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo an where contents-were disposed:
Lowell Waste Water
Sign e I Houle � Date
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