HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 LACONIA CIRCLE 4/22/2024 Commonwealth of Massachusetts :ytitn;
W City/Town of _ALL:L , ,AOde%�,t r
System Pumping Record APR 2 2 2024
Form 4
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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, IG.
use only the tab i Z v a �L✓1 2 r�e
key to move your Address
cursor-do not &(>(-4-k C'I S
use the return
key. City/Town State Zip Code
2. System Owner
nth me d S aka
Name
mnm
Address(if different from location)
City/Town State Zip Code
't79' 5-Z (;7-(o
Telephone Number
B. Pumping Record
1. Date of Pumping r f Ztl 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) 1 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E�j No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
�q c—uA
s. System � y.�1 W l94 ,0
Name Vehicle License Number
Company
7. Location where contents were disposed:
-`J
Signature Haule Date
Signature of heeeMng Facility(or attach facility receipt) Date
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