HomeMy WebLinkAboutSeptic Pumping Slip - 171 LACONIA CIRCLE 7/31/2017Cornmonwealth of Massachusetts
CitY/Town of . •
System Pumping. Record
Form 4
DEP has provided this form. for use.by local Boards Of Health. Other foTr°rrli-filOWN OF NOri.R.T,HhA400 113:VuEtRthe
informationmust 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.
V
JUL 2017
. A. Facility Information
1. System Location: Left / Right front of house, Left , Left / right side of house, Left /
Right side of building, Left / Right frOnt of building, Left Right rear cif building, Under deck
Address
City/Town
2. System Owner.
Name'
re)e
State
Zip Code
Address (if different from location)
cCity/Town' State2z-,
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
-1)7
2. Quantity Pumped:
Gallons
3. Type -of system 0 Cesspool(s) Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? El Vas
' 5. Condition of System:
fUocucc.c./e
If yes, was it cleaned? 0 Yes El No,
6: System Pumped By:
Nell. Bateson
Name
Bateson Enterprises Inc
Company
7. Lo contents -were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Sign e. Hauler( Date
5form4.doc. 06/03 System Pumping Record • Page 1 of 1