HomeMy WebLinkAboutSeptic Pumping Slip - 171 LACONIA CIRCLE 8/15/2018 Commonwelalth of Massachusefts RECEIVED
wi awn f
; AUG 15 0 ski
Fonn 4 TOWN OF NORTH CAL"r�N i�I�;a ai�.MEN 'r 1
DEP has provided this form for us&by local Boards o'Mealth. Other forms may be'used,but the
inforrnation�must be substantially the game as that provided here. Before using.this form:,check with your
local Board of Health to determine the forth they use.The System pumping Record must be submitted to t
the local Board of Health or other approving authority.
A. Facfll�ty. Information
1. system Location: Le /Right front of Mouse, Left I hoof haus , Left/right side of house, Left,(
� Right side of building, Left/Right front of building, Left/Righ rear®f building, Under deck
Address
Tity/Town State Zip Code
2. System Owner:
Name
Andress Of different from location)
Citylrown Stajea tom, Cod ---J
"telephone Number
. i
l
1. bate of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: Cesspools) eptio Tank El Tight Tank
i
® Other(describe):
4. Effluent Tee Filter present? ® Yep o If yes, was it cleaned? Yes NQ
' 5. Condition of?Ys em• /j "�, � ��� "
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Iris•
Company
?, Lo
Ie e contents-were disposed: 1
t
G SLowell Waste Water
OA B 0�
Sign a 1i�ul Cate
t fbrm4.doc-06/03 System Pumping Record d Mage 1 of 1