HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 9 LACONIA CIRCLE 12/19/2024 Commonwealth nfMassachusetts
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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 be substantially the same as that provided here. Before using this fonn, check with your
|oou| Board of Health to determine the form they use. The System Pumping Record must be submitted to
the |oom| Board of Health mr other approving authority within 14 days from the pumping dote in
accordance with 31OCK4R15351.
A~ Facility Information
Important:When
filling out forms 1. System Location:
un the computer,
use only the tab 9 Leconie Qvc|o
key x,move your Address
cursor-do not
NodhAnduvor MA 01845
use the return
k«v. City/Town State Zip Code
2. System Owner:
~---� Jarred Matyka
ame
Address(iCdifferent-from location)
781-771-8792
elephone Number____
B. Pumping Record
12/19/2024 1500
1. Date of Pumping 2. Quantity Pumped:
Date
3. Type ofsystem: Fl Cesspool(s) Z Septic Tank Fl Tight Tank n Grease Trap
n Other(describe):
4. Effluent Tee Filter present? Yes Z No |[yes, was itcleaned? Yes Z No
5. Condition ofSystem:
Good system operatingproperly
S. System Pumped By:
Jason Elliott S71437mrV8�257
ame Vehicle License Number
|vesterund Elliott Services LLC'DBAJaaon
Elliott Pum i
Y. Location where contents were disposed:
{5LSD