HomeMy WebLinkAboutSeptic Pumping Slip - 60 LONG PASTURE ROAD 3/14/2016 Commonwealth of Massachusetts RIE�'CEIVED
u W City/Town Of
System Pumping,Record �-H pj,g)OVEIR
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
I. System Location: Left/Right front of house, Left/Right rear of house rig de of house Left/
Right side of building, Left/Right front of building, Left/Right rear of buuirding, Under dec
Address _
Cityfrown ( State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown state C d. eZ j Code
i
Telephone Number
B. Pumping Record p .. - �
1. Date of Pumping pate 2. Quantity Pumped: Gailans —�
3. Type of system: ❑ Cesspool(s) eptic Tank Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio of stem:
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
SignAtufe I Haule Date
t5forrM.doe-08/08 System Pumping Record•Page 1 of 1
Commonwealth of chu fit
RECEIVED
u City/Town of
S tem Pumping Record
YS
Form 4 11 OWN()Ir MDR PI ANDOVER
HEAI-n� DE113M'�'rMENTJ
DEP has provided this form for use by local Boards of Health. Other forms m❑y❑"e❑se"" , ut fh'e
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 house, Left/Right rear of house right/, i o of hawse. Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under dec
Address
Cityrrown ( ' State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stat I �d
Ce
( _
Telephone Number
B. Pumping Record �.
1. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ ept c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
' 5. Conditi System:
-
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign t e Haule Date
t5form4.doc«06103 System Pumping Record m Page 1 of 1
TO" OF NORTH AN OVER
SYSTEM PUMPING R_ECOR_D
51'EM OWNER & ADDRESS , SYSTEM LOCATION
(
Ma Ie; Icf( Iron( or house.
A,
s
C
U:\Tc OF PUMPINC: /C QUANTITY PUMPC, D,,�°'—
0,\ L 1.
NO YES SEPTIC TANK : NO YES ��
-,TUBE OF SERVICE; ROUTINE EMERGENCY
GOOD CONDITION, FULL TO COVER
HEAVY CREASE BAFFLES IN PLACI;
ROOTS LEACHFIELD RUNBACK.,
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER P HRR (EXPLAIN)
c u,II
r N T S
U'�"I k'NT1 TRANSFERRED TO: