HomeMy WebLinkAboutSeptic Pumping Slip - 285 REA STREET 3/1/2016 Commonwealth of Massachusefts
C4/Town of
n Pumping �l U 'i "1 2014
sv
For rot ANDUM k
i� HEAL'o a MEET'
inEPmati nrmust be the same that provided here. Before using-this ibut the
y
info Y p .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 ether approving authority.
A. Facility Information
_
1. System Location Legit t ont of house,.^deft/Right rear of house, Left/right side of house, Left/
Right side of boil " eft/ ig ran o uildidg, Left/Right rear of building, Under deck
City/Town State Tip code
2. System Owner: ,
Name
Address(if different from location)
CityfTown 5tat � � ipfode
Telephone Number
B. Pumping Record
1. late of Pumping C1ate - —�eptic anti roped: canons
'a
. Type of system: Cesspool(s) Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Yep 0 No If yes, was it cleaned? a"VesO No.
5. Condit' n of Syste
C -s
6. System Pumped May:
Nell Satesbn F5321
Name Vehicle License Plumber
6ateson Enterprises Ino
Company
7. 481gnt here contents were disposed:
) Lowell Waste Water
Houle gate
t5form4.doc-06103 System Pumping Record«Page 1 of 1
Commonwealth of Massachusetts
f
City/Town o
S ' tem Pumping Record
ys
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
Rig t-ffon o'
L'6' f haws Left/ house, Left/right side of house, Left/
1. System Locatio I �o � Right rear of h
Right side of buq1�: 1WL4, Left/ IgTTrbont of building, Left/Right rear of building, Under deck
Address
State Zip Code
City/Town
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pum ping 2. Quantity Pumped: -da-llons ,'
3. Type of system: ❑ Cesspool(s) [D--Septic Tank ❑ Tight Tank
0-10ther(describe).
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
S. Condition of System-
a
�-j
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Nu 'bar
Bateson Enterprises Inc
Company
7. Locat' er_e contents were disposed:
L S. Lowell Waste Water
Sign to e Haule Date
System Pumping Record-Page I of I
t5form4.doc•06103
Commonwealth of Massachusetts RECEIVED
City/Town of ° ()l'
e System Pumping Record i-UNNOFH I.I AANDOV 1�z
a
Form 4
N Pr
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 Lof bui din Left hR ghtt f®f p Left/Right rear of house, Left/right side of house, Left/
r g
Right side g, wilding, Left/Right rear of building, Under deck
Address
CitylTawn
State Zip Code
2. System Owner: w
Name
Address(if different from location)
Cityfrown
State(—) Y , ,P
Telephone Number
in Record C ::
. Pump .
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: E] Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? ❑ Yes [I No
5. Conditio of,System
OV-
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. JGL uyhene contents were disposed:
Lowell Waste Water Haule Date
t5form4.doe•06/03 System Pumping Record•Page 1 of 1