HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 LACONIA CIRCLE 11/10/2025 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 hens. 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 310CPWR15351. . 'I.
A. Facility Information Ver
Important:When NOVfilling out f"nnv 1. System Location: '`"^ �07c
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use only the tab 20 Laconia Cin:|m
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2. System Owner:
~--� Ga ry Rich
Name
ress(if different from location)
508-423-1777
Te�hone-N umber
B. Pumping Record
1. Date of Pumping oa/e 10/15/2025 2� Quantity Pumped: 1500
Gallons
3. Type ofsystem: Cesspool(s) E Septic Tank F-1 Tight Tank R Grease Trap
F] Other(describe):
4. Effluent Tee Filter present? Yes No |f yes, was itcleaned? Yes No
5. Condition nfSystem:
Good, system operating properly
G. System Pumped By:
Jason Elliott S71437 orV85257
Vehicle License Number
|vmater and Elliott Services LLC-DBAJason
Elliott Pumping
7. Location where contents were disposed:
GLSd