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HomeMy WebLinkAbout- Septic Pumping Slip - 20 LACONIA CIRCLE 12/6/2018 N irlry( a Commonwealth of Massachusetts 0 w City/TownPumping of h Record ' W �,,�. System d r 7 Form 4 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. __---_____-—___--------------- --.....--------....--.-...... A. Facility Information Important:When filling out forms 1. System Location. on the computer, use only the tab 20 Laconia Circle key to move your Address cursor-do not North Andover MA 01845 use the return key, City/Town State Zip Code 2. System Owner: Gary Rich Name radm Address(if different from location) Crty/Town State Zip Code 508-423-1777 Telephcne Number B. Pumping Record 11/30/2018 1500 1. Date of Pumping -- 2, Quantity Pumped: _ bate Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank © Tight Tank ❑ Grease Trap ❑ Other(describe): _ .... _._...__._._._. 4. Effluent Tee Filter present? Yes ® No If yes, was it cleaned? Yes ® No 5. Condition of System: Good, system operating properly 6. System Pumped By: Jason Elliott S71437 Name Vehicle License Number Ivester and Elliott Services LLC-DBA Jason Elliott Pumping 7. Location where contents were disposed: GLSD 11/30/2018 RSiaw--r'of Hauler Date Signature of Receiving Facility Date I t5form4.doc•03/06 System Pumping Record•Page 1 of 7