HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 150 LACONIA CIRCLE 1/12/2026 s City/Town of
n SysteM Pay pin
g
Record A IV 2 2(°
%< �VV f orrrt 4
cal Boards of
o of rmationr rr n�.sf hf:�.�subs(anlii,�lly�frhe�Saone as lhaf prov�idedlh re. Before usealt . Other forms'zing
local Boafd of Health fo dete,rrnlnea the form the use, he ���� f�t�r r F�c co� �rd must be saal7mMed to
the local Board of Health c)r othe( approving Authority within 14 days from tfe pumping) data in
accorda nce, with 31C) C.MR 15,3 1
_ f-1OUSE: frorbt ack sicJe rear left r
A. Facility lnformatior`l 4WII.DINGi front heck side, rear left r
Important wf7rsn y Df:CCK: under
f tined out forms 1 Sys(e' ii Location
on IN, comp Ior, ' ` /"� C �) &�,v-o,(
4
use Only We lab
kuy(o move your Ad(jrrass
cursor do not
u S c I1 G r e l U fl , __ ,.._... —.tt �" _-�. _...__... _� .....__. .. .^...^
kefy f (;,(r,, LIp Corte
y� ., ` E l �WnEfj :�,
, _..__._,__.__.
y uv�r
A(Jdross If (1lfit;rof)r (ro( rn I0(,alic')ri)
VA
C,fly i own lair Ip Code
7eleptione t umber
S. Pumping Record
1 Uate; of Purr7fDinr1 Ui�,_ ._ __...._.... 2. Quantity Pumped j -? .__..--- ___..___
C111ons
3. Corrrpor7cn(. (._..� Cesspool(s) IC,Tank -right 'Tank (—) Grease Trap
Other (describe)
,1. F:P(Ivent Tee F=(ICe,r fares r l? [_] `"€,rs ( . (rdo !f ye',s, was it Cdeaned? [._.) 1'r;s (3 o
5 Obsefved condition (')f cornponenl p(jrnped
G. Sys n Pur, t(red By
D yr Ifr(r r( Mass 1 ,aX95E M<,s IAD31z
_ _... _._
_ _..
N�
................._..............
�7 L10 c;alfo wlr%V` rltr�"n.,15 ware disposed
wl(�n'd51tn+.. o(Ei,¢;"CeYvlrSy f ,nCilily (or £iU<r,;h (t7uilt(y rr;e,Gif d) ('jalr,
l
`>Iom(4.Cioc 11f12 System Purnpine) Reccucl Page; '1 of 1