HomeMy WebLinkAboutSeptic Pumping Slip - 491 SALEM STREET 3/4/2016 11 NlY 11 J
_ Commonwealth ®f Massachusett
City/Town of North Andover MAY l] ) ,20 3
System u in rctw
Form 4 w��P� �� p ���,1,-ii✓�i N
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 forms 1. System Location:
on the computer, 491 Salem St
use only the tab _
key to move your Address
cursor-do not North Andover MA
use the return
key. City/Town State Zip Code
2. System Owner:
- tab
Lascola
Name -
tenon
-------- -- - - ----------
Address(if different from location)
City/Town - State -- Zip Code
Telephone Number
B. Pumping ecord
1. Date of Pumping 4/21/2014 1500
Date — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? I® Yes ❑ No If yes, was it cleaned? ® Yes ❑ No
5. Condition of System:
Good
6. System Pumped By:
Thomas Mute____ _ M79-896-(BHP-2014-0136)_ ____
Name Vehicle License Number
Wayne's Drains
Company - -
7. Location where contents were disposed:
Lowell Regional Waste Water
4/21/2014
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
ar�wrm!w�w!a�.warcs �uuv e�rourw�iuuoww
s Commonwealth Of Massachusetts
a City/Town of
g System Pumping
Form 4 C)
tB I°�C: ` i u' CL
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 hour. f Left/R,ear ... .u
t/1igfrear of house, Left/right side of pause, Left/
Right side of building, Left/Right front of building, Igt rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stag Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) D eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
& System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location„here contents were disposed:
Lowell Waste Water
til
Sign toe I Haule Date'
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
IL
Commonwealth Of Massachusetts
= x C ity/Town of
System Pumping Record
Form 4 o,k
k
M 1 ,,
DEP has provided this form for use by local Boards of Health. thu Rr,19r p y i!l # ut the
information must be substantially the same as that provided he e. Before using�thtsiforTm, heck with your
local Board of Health to determine the form they use. The System""pumping r ecord must e submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house�Lef]Righ jee! r of housC Left/right side of house, Left/
Right side of building, Left/Right front of bulging, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
V u
Name
Address(if different from location)
City/Town Stat I Zip Cade
(4
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Type of system: ❑ Cesspool(s) ® eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 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
Sign to'e I Hauler Date
t5form4.doc•06103 System Pumping Record.Page 1 of 1