HomeMy WebLinkAboutSeptic Pumping Slip - 1475 TURNPIKE STREET 2/25/2016 Commonwealth of Massachusetts
City/Town of
Pumping System r
Form 4
F fis
DEP has provided this form for use by local Boards of H alth Other forms may be used, but the
information must be substantially the same as that provided here,, ip tt i form, check with our
9� Y
local Board of Health to determine the form they use T )� cor must be submitted to
the local Board of Health or other approving authority,
A. Facility Information
I. System
eft g h r /, et t re ar_o.w.f...hod
s
f fihr ro Left/right side of house, Left
Ri g ht side of building, Left Ri g ht front of building Left fbuilding, /
Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State J4 Zip Code
c... \
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ®' Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 10_y s DAre, ' w-
If yes, was it cleaned? ®-'��s"�W❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S
_'6.L . _' Lowell Waste Water
Sign t Date
t5form4.doc^06103 System Pumping Record>Page 1 of 1
Commonwealth of Massachusetts �
City/Town f
N System Pumping Record
y` Firm 4
k � fl y
be Used, but the
DEP has provided this form for use by local Board a �, i,„ �
information must be substantially the same as that Wded ” g this form, check with your
local Board of Health tQ 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 side of house, Right side of house, Left front of house, Right front of house,
ft�.of h§r W'.Right rear of house. Left rear of building. Right rear of building.
Address ._ry
q
State Cik flown
y e Zip Code
2. System Owner:
Name ------------- --- --------- __
-- — ---- ----------- — – --
Address(if different from location)
---
City/Town Stat------------------------
--M Zip Code
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? es ❑ No If yes, was it cleaned? ❑"Yes ❑ No
5. C ion of System: � M„
m
6. System Pumped By:
Neil Bateson F5821 _
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where,contents were disposed:
L w i Wast Water f
Signat re H ler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1