HomeMy WebLinkAboutSeptic Pumping Slip - 171 LACONIA CIRCLE 8/31/2015 : Commonwealth of Massachusetts
City/Town of
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.
A. Facility. Information
1. System Location: Left/Right front of house, Left Afighti rear of houses, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left Ig a of building, Under deck
Address
City/Town State Zip Code
2. System Owner. 1�
V:-)
Name'
Address(if different from location)
Citylrown ' State sy Zip Code ;
F +J5
Telephone Number
B. Pumping JRpcord
1. Date of Pumping Date 2. Q antity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 01 o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: y6A �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati/"h7e contents were disposed:
jSign gHaule Lowell Waste Water
Date
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