HomeMy WebLinkAboutSeptic Pumping Slip - 114 STONECLEAVE ROAD 3/3/2016 Commonwealth Of Massachusetts �w o
RECEIVED
City/Town of
Sysitem
Fora' 4
Q ELF NOM11i11"iAP IDO
DEP has provided this form for use by local Boards of Health. " ut 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 Informati®n
1. System Location: Left/Right front of house, Left Right rear of house, Left/right side of house, Left/
Right side of building, Left/ Right front of building, Left Right-rear of building, Under deck
Address L ,r (
Cityrrown 1 State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State lip Cod
.w.
Telephone Number
B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) a Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? 0-Yeds❑ No
5. Conditi n o System: w
a
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company ,
7. Locati rr-wpefe contents,were disposed:
G L S. Lowell Waste Water
Sign toe I Haule Date t
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth Of Massachusetts
a City/Town Of
� a 9
a System Pumping Record
y40"O
W
Form 4
�l PVI�I fa II lr I F
DEP has provided this form for use by local Boards of Health. Other formsr min he
information must be substantially the same as that provided here. Before usiilthisfrrt; ith 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, Lefl:1A tt rea�hs Left/right side of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
' '
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p ® 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. Location where contents were disposed:
L S Lowell Waste Water
r
6-
Sign to a Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
a�
Commonwealth of Massachusetts
-
City/Town of
System Pumping Record
Form 4 "� 1 �
TOWN F NORTH i&AN�)t.VER
DEP has provided this form for use by local Boards of Health. Oth r f s° a�be put he
information must be substantially the same as that provided here. Be ore using i s arm,c eck 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 side of house, Right side of house, Left front of house, Right front of house,
a ause Right rear of house. Left rear of building. Right rear of building.
----
-----
------- --------
Address (
City/Town State Zip Code
2. System Owner:
-
Name -- --- -
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping ecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [71 Septic Tank ❑ Tight Tank
❑ Other(describe): ------------ - --
4. Effluent Tee Filter present? ❑ Yes ® 1 .... If yes, was it cleaned? ❑ Yes ❑ No
5. Can " 'on of Sy tem:
. U�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company -- ------ ------
7. Location where contents were disposed:
G.L.S Lo II Waste Water
- ------- ------
Signatu of er Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1