HomeMy WebLinkAboutSeptic Pumping Slip - 89 WINDSOR LANE 3/3/2016 I ttp
`r Commonwealth of Massachusetts
City/Town of J��[��� �x r' „ f,'�;i
-
System PUM ping Record NORTH
I
V if.�dii ii .i r
kl
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351,
A. Facility Information --
Important:
When filling out 1. System Location:
forms on the C,
computer,use !. dam-/ ` ✓(� .±._.- ---- - - .___..-_. .,. _
only the tab key Addre //��-�__� ±�� }
to move your � �./�!,Gt!�t/_ "f�" l, l
cursor-do not -- __..._ ._..use the return CityLTown State Zip Code
key. 2. System Owner.
m —....
Name
"419 Address(if different tram location)
—- --
State Zip Code
City/Town �„.,.
Telephone Number
B. Pumping Record
1. Date of Pumping - ate 2. Quantity Pumped: Gallons
D
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter resent? Yes ❑`°'" °.
p ❑ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Wind River Enviromental vehicle Lice �
Name ---- 163 License Number
--- lout r,_ 01930... .
Company
7. Location where contents were disposed:
Signature of Hauler Date
--igna—l_--"o---- ----.--.._
Signature of Receiving Facility' Date
15form4.doc-03106 Systern Pumping Record-Page I of 1
Commonwealth of Massachusetts
City/Town own cif
System Pumping ec r
_ Farm 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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information -
Important:
forms on the �C „,
came utruseut Y f ?
filling 1. System Location:
n
only the tab key Addres
to move your .. -.
cursor-do not
use the return CityfTown Stale Zip Code
key. 2 System Owner:
» �� _ ✓
Name C _..
IjAkNl 1U,
— ------------- --- --.-._.. .
Address(if different from location) ,
Cityrrown St t - Zip Code
.Tale"yh�one umber
� C _
e p
B. Pumping Record _
1. Date of Pumping ---_Gallons
Oate .� - _---- � Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ( ,,�.eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑} Yes ❑ No
5. Condition of System:
6. System Pumped By.
-------�is- . ._. _. L i Name Vehicle tVum er
Company
; Location where contents were disposed:
WA
- - '
S—_na—l' -- - --
ignature of—Receiving-------Facility—---- —
Date- -
l5fo(m4.doc-03/06 System Pumping Record•Page i of t
Commonwealth of Massachusetts
r W
FHEAUTH City/Town of
System Pumping Record Fl ANDOVER
4 Form DEPARTMENT
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
6
computer,use G w r r.c S e i e^
only the tab key Address
to move your
cursor-do not —. --- - -- --
use the return
City/Town State Zip Code
key. 2. System Owner:
tdL"j ' ------_ ..-_..............._.
Name
Address(if different from location)
---- --------------
City/Town State Zip Code
& 0-31
Telephone Number
B. Pumping Record
1. Date of Pumping —at 2. Quantity Pumped: --ns—
D Gallo
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - -----
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
od
6. System Pumped Py;_
--Vehicle-----License--e----------Number
Company
7. Location where contents were di sed:
Signature of Hauler Date
--------------
Signature--------of-Receiving--- Facility— Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
:;�;6� Commonwealth of Massachusetts kckuttl
City/Mown of N TN AND M a �
A
System Pumping ecord
�w
�- Farm) 4
DEP has °Cr1111�P e"�i �U /P�r kr7 %i
p Y �� y.. 1 1' k cord must
be submitted to the local Board of Health or other approving a tharttys�el u h.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
cursor-do not Address
to move your /� CG
only the tab ke y
use the return City/Town State Zip Code
key. 2. System Owner:
Name —
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pat 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ,,k, eptic 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:
f
Name / Vehicle License Number
Company
7. Location where contents were disposed:
Si nature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
15form4.doc•06/03 System Pumping Record o Page 1 of 1
Commonwealth ofMassacbusetts
Massachusetts
$ygitem Pump-10-9 Record
System C)wner - System location
,,d
late of 1'u1nping:f ( 0 Quairtity Pumped: IS A gallons
Cesspool: No Ves Septic Tank: No Yes
System Pumped by: Edeedare License #
Contents tianslerrred to : Greater rawrence e►tltsaYV Rl trlct —
Date: _�.----- -------- lnspector _—
