HomeMy WebLinkAboutSeptic Pumping Slip - 85 LACONIA CIRCLE 7/31/2017Commonwealth of Massachusetts
City/Town of .
System Pumping. Record
Form4
DEP has provided this form for usesby 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 / Right front of house, Left / Right rear of house, Left I it side of hotisi.7. Left I
Right side of building, Left / Right front of building, Left / Right rear cif building, Under deck
Address
City/Town
2. System Owner.
SE_ Q
a� E
State Zip Code
Name.
Address (if different from location)
City/Town •
State.
Telephone Number •f` }
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type•of system: [] Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? 0 Yes 13 If yes, was it cleaned? ❑ Yes ❑ No,
" 5. Condition of System:
6: System Pumped By:
Neil. Batesbn •
• Name
Bateson Enterprises Inc.
Company
7. Location vuhere contents were disposed:
Lowell Waste Water
F5821
Vehicle license Number
t5forrra4.doa• 06/03
System Pumping Record • Page 1 of 1