HomeMy WebLinkAboutSeptic Pumping Slip - 150 Laconia Cir - 11/4/24 - Septic Pumping Slip - 150 LACONIA CIRCLE 11/4/2024 Commonwealth of Massachusetts
C�ty/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be used, W the
information FnLJ9t be substantially the same as that provided harp. 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 .he pumping date in
accordance with 310 CMR 15.351,
fr
o
HOUSE fro t back side rear left Grig igh
BUILDING� --TF6nt back side rear left r g A. Facility Information It
Important:When DECK: under
Male
ofoy c onn the computer,only the tab
key to move your
cursor do not MA
use the return
key. Stale Lip Code
2 Sys rn Owner
Ln"A Name
MA
ly own Stale Z!p Codp
Telephone N u m e r
B. Purnping Record
(,Z)
1. Date of Pumping ei 2 Quantity Pumped'. Gallons
3. Cor-n pon e n t Cesspool(s) .. Sept 'Tank _] Tight Tank Grease Trap
E. Other (describe): ............. ----------
4 Effluent Tee Filter present? Ej Yes If yes, was it cleaned? E Yes ❑ No
5, Observed Condition of component pumped,
G. System Pi,jrnped By.
Dave Tiney Mass IAA95E Mass IAD31Z
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Name -- Vehicle LIcense Number
B2teson Enterprises, Inc
Company
7 Location where contents were disposed
GL5D
'S7 P
tqnatuie ol! Hauler JatE
----------- ---------
gnature of Receiving racFility or attach facility receipt) Date
t5iorm4,doc- 11112 cystenn Pumping Record - Page 1 of 1