HomeMy WebLinkAboutSeptic Pumping Slip - 135 LACONIA CIRCLE 6/15/2017 ` ►, Commonwealth of Massachusetts
ati /Town ofPee 0, so
pstem Pumping.Record0.
DEP has provided this form for use:by local Boards of Health. Other form's maybe 1 ed,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 Informlation
1. System Location: Left/Right front pf hous Le igh ear�rear
, Left./right side of house, Left/
Right side of building, Left/Right front of bul Mg, Left t igbuilding, Under deck
Address
Ck
Citylfown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' -. State� �p�r ti Zip Code ;
f Telephone Number f`'{
Pumping (Record
1. ®ate of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of s stem:
yp system. ® Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe).
.4. Effluent Tee Filter present? ❑ Yes ❑--No If yes, was it cleaned? ® Yes ❑ No,
5. Condition of System.
�jo ��- v�
6.- System Pumped By:
Neil.Bateson F5821
Name Vehicle!license Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
GLLowell Waste Water t
F
�- a SA
Signitu a Haul Date
;Morm4.doc•06/03 System Pumping Record•Page 1 of 1