HomeMy WebLinkAboutSeptic Pumping Slip - 72 WINDSOR LANE 3/11/2016 commonwealth ®f Massachusetts
City/Town af
r R
- y ter Pumping eeer
Form 4 ..,
y 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:
1 S
When filling out stem Location:Y
forms on the t
computer,use Address 4
only the lab key
"' p
y City(Town "� - � —
to move our � � , Code
cursor-do not State
use the return
key.
2. System Owner-,
Name
%+� Address Qf different fror,-i localian)
-. —. .. �Stale Zip Code
Cify(T:own
--, � .
Telephone Number _.
B. Pumping Record — --
- Y Gal
�t �� .. —_ 2, Quantity Pumped:
1. Date of Pumping Date ions
3. Type of system: ❑ Cesspool(s) [ optic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? [ Yes ❑ No If yes, was it cleaned? P �es ❑ No
5. Condition of System:
Cel C"
r ,
6. System Pumped By �
Name Vehicle License Number
4
company
7. Location where contents were disposed:
Date
Sign �b 6�'Haulel� � r
Sigeialure of Receiving Facility Date
15form4.docc 03106 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts ..
City/Town of
a
System u pin Record
r` Form 4
DEP has provided this form for use by local Boards of Health. Other forms ma tbttat» i� � ,,,,
information must be substantially the same as that provided here. Before usm his 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
computer,use d t v, vx
only the tab key Ad re
to move your
cursor- nok AN00-\Mft4- -
use the return y/T Citown State Zip Cade
key. 2. System Owner:
ft
Name
rr�.s Address(if different from location)
City/Town State Zip Code
M--C 8 '?-/7°70
Telephone Number
B. Pumping Record
1. Date of Pumping r _ cN 2. Quantity Pumped: { � �
p g Date y p Gallons
3. Type of system: ❑ Cesspool(s) R Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? El Yes �o was�t gleaned? ❑ Yes El No
g,
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
AfE k
Comp ny
7. Location where contents were disposed:
Signature f aul Date
Signature of Receiving Facility Date
t5form4.doc-03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
<< City/Town of NORTH ANDOVER„ MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health The S)rstem Pumping Record must
be submitted to the local Board of Health or other approing fray
A. Facility Information MAY
Important:
When filling out 1. System Location;
forms on the
,
only petab key Add ess f �...-
he
to move your w�_ (�, Q . • �.. ,,.�
..
cursor-do not lk
use the return City own State Zip Code
key.
2.v rob _System n h
e r:
Name — —
Address(if different fr n_look patio )'
7 r
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate I I +, 2, Quantity Pumped: '
Gallons
3. Type of system: ❑ Cesspool(s) (,Septic Tank ❑ Tight Tank
❑ Other(describe): --- — _
4. Effluent Tee Filter present? [ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Systems Pumped By;
— �1
Name Vehicle License Number
Com P a-n-y7t, t
7. Location where contents were disposed: `
(� ( �.. w,.
Signature Date
e C) m....�, 1_
of Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts °
City/Town of
y `t r
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 y
RECEIV
A. Facility information
Important: tem Location:
forms onI'the out Y mow' , , d � tlt1 t MI")d NU t R
1. system
computer,use - if f
only the tab
to move youkey Addre s And
r,
cursor-do not State� - -_ -_ ..---- --- ------ _
use the return
City/Town Zip Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
2. Quantity Pumped: —
_ -
1. Date of Pumping Date y p Gallons
3. Type of system: ❑ Cesspool(s) f 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:
6. System Pumped By
� 4
i „„", -- - License Name Vehicle ic)
" — --- Number-
Company
7. Location wber contents were disposed:
n f ��" u
9 --
Si ature Date
Si at
gnure Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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FORM 4 s SYSTEM PUMPING RECORD
CURRIER
SEPTIC & DRAIN SERVICE q,\
107 FOREST STREET;MIDDLETON,MA 01949
(978)7742772
COMMONWEAJJH OF MASSACHUSETTS
MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER: SYSTEM LOCATION:
4
DATE OF PUMPING: QUANTITY PUMPED: /Sc®c) GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: S
r
DATE: r INSPECTOR: "