HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 7 LACONIA CIRCLE 5/13/2025 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 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 310CK4R15.351.
A, Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tam 7 Laconia Circle
key m move your Address
cursor do not
North Andover ��A U1O45-33O4
use the return
o�Town State Zip Code
_'�
2. System Owner:
~---~ John Km i
ame
Address(if different from location)
-6-ty/Town State -- Zip Code
617'721-5188
Telephone Number
B. Pumping Record
5/13/�O25 15UO
1. Date of Pumping �� Quantity Pumped�
3. Type ofsystem: El Cesspool(s) Z Septic Tank 0 Tight Tank El Grease Trap
LJ Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? Yee E No
5. Condition ofSystem:
Good system dnproperly
6. System Pumped By:
Jason Elliott S71437orV86257
|vedarond Elliott Services LLC-OBAJuaon
Elliott Pumping
7. Location where contents were disposed:
BLSD
5/13/2025
%S15re of Hauler Date
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