HomeMy WebLinkAboutSeptic Pumping Slip - 20 Laconia - 10/16/24 - Septic Pumping Slip - 20 LACONIA CIRCLE 10/16/2024 Commonwealth Massachusetts
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System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must he substantially the same aa 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 ur other approving authority within 14 days from the pumping date in
accordance with 3iOC[WR1S.351.
A~ Facility Information
Important:When
filling Outmms 1. System Location:
on the computer,
�ULeinde
�����o�� Laconia Circle
key to move your Address
cursor-do not
North Andover [WA 01845
use the return
--
key. ~'°''~—' State Zip Code
2. System Owner:
~---~ Gary Rich
own State Zip Code
508-423-1777
-telephone Number
B. Pumping Record
1O/1G/�0�4 1. Date of Pumping 2� OuandtyPump�d� 15OU
Gallons
8. Type ofsystem: F1 Cesspool(s) Septic Tank Fl Tight Tank Fl Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yea No |f yes, was itcleaned? Yes No
5. Condition ofSystem:
Good, system operatingproperly
G. System Pumped By:
Jason Elliott S71437 or V85257
Name Vehicle License Number
|veoter and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
8LSU