HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 171 LACONIA CIRCLE 7/31/2020 Commonwealth of Massachusetts .Y9
City/Town of
System Pumping Record JUL 312020
Form 4 F 91,D 0 F P S tea.-`
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.
A. Facility Information
1. System Location: Left/Right front of house, LeftVe
gh rear of house Left/right side of house, Left
Right side of building, Left/Right front of building, lg rear of building, Under deck
Address � ,}7
Cityfrown State Zip Code
2. System Owner.
Name' \1
Address(if different from location)
CitylTown stater
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ai' o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle Uoense Number
Bateson Enterprises Inc
Company
7. Loca' w ere contents,were disposed:
lL L S. Lowell Waste Water
�� a or
Sign a 9t HaulW
8j Dabs
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