HomeMy WebLinkAboutSeptic Pumping Slip - 1907 SALEM STREET 2/24/2016 Commonwealth of Massachusetts
=
City/Town of
Pumping r
Y 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/ ight rear of Whouse, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Righrrear of building, Under deck
Address ��� ,_�,.,✓�.� `" � ``� �,,�....
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State L , .. p Code
Telephone Number
B. Pumping Record -,... 4.
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [] Yes ❑ No If yes, was it cleaned? E]-Y69 No
5, Condition of S stem:
..w
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number°
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
L S, Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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 CR`k�gc-Rt rear of h eft/right side of house, Left/
Right side of building, Left Right front of building, Le—ff-Mkgfifrear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
G
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system. ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiqn-w4ere contents were disposed:
G&S. Lowell Waste Water
Sign toe HauleV -Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVED""
E
R ER�
City/Town of
System Pumping Record S ,
1
1
SEP ? ?01
Form 4
0
LTOWN OF NORT�,f MMOVER
M�eu$6
DEP has provided this form for use by local Boards of Health. ''Tb ed but the
is OrM.
information must be substantially the same as that provided here. Before using t is arm, 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 front of house, right front of house, left side of house, right side of house, Left
rear of house�a!'gb66-ar-o-f h ous-eje side ht ft e of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from—location)
-City/Town Sta Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) [Tt'e-ptic Tank ❑ Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? Y,e I s ❑n No If yes, was it cleaned? B"'Y"e"S"D No
5. Condition f S stem:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locptionwpere contents were disposed:
.L.S. 1 w4 Waste W6itery,"')
Signature o H ule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
IL
Commonwealth Of Massachusetts
City/Town of
System Pumping Record
Form 4 ��� �p 'C 0 1(
DEP has provided this form for use by local Boards of Health. Other forms Ty w OVER
information must be substantially the same as that provided here. Before us' r
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 front.-of...!� se,, right front of house, left side of house, right side of house, Left
rear of house fight-'rear of fi us_e,�.teft�`side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Gate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): -- — — -- — ---
4. Effluent Tee Filter present? ❑ Yes - ., If yes, was it cleaned? ❑ Yes ❑ No
e
5. Condign f S '
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locationwh re contents were disposed:
.11
G.L.S Owell WasjV
(77��
Signal re H uler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1