HomeMy WebLinkAboutSeptic Pumping Slip - 44 MARIAN DRIVE 3/15/2016 Commonwealth Of Massachusetts `W" +W°wy.�
City/Town Of
System Pumping - k
Form 4
[11,"MN NORTH N�1t�VER Cfl- DEPAR°t° ENT DEP has provided this form for use by local Boards of Hea a d, 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. Systm.,.Location: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of houe Right rear of house. Left rear of building. Right rear of building.
----- ---- -----
Address --- —
w
City/Town State Zip Code
2. System Owner:
- — ----------
Name - - --
-- — — ------------- -- - -- -- - - -
Address(if different from location)
------ —-- - - ------
City/Town State Zi p Code
Telephone Number
B. Pumping Record
Cf
1. Date of Pumping - -- - 2. Quantity Pumped: ---- — -- -
Date Gallons
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. Cqndilim of S
yst m:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
I *.G S.D� Lowell Was ater
Signature f H er Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
w ity/Town Of
- - System i ng Recor
Form 4
'ALMA,
DEP has provided this form for use by local Boards of Healt „f d, but the
information must be substantially the same as that provided here. is fo check with your
local Board of Health to determine the form they use. The S stem Pumping Record m st be submitted to
the local Board of Health or other approving authority.
A. Facility nformation
Y �°OWN F�NOAH AirMAA �A
_W.
I JEAN�A o����:�A rrmI u:�,���.
1. System-L vacation: Left front of house, right front of hous �We af�w'Ti'g de of houSp,.Le
rear of house right rear of house, left side of building, right rear of building, under deck.
-----------------
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
------------
- ------------ --------
City/Town Stat --Zip Code
C o
Telephone Number
B. Pumping ecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? Des No
5. Condition o Sy tem:
6. System Pumped By:
Neil J. Bateson F5821
---------- --------------- ----
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. LocatiQjl,where contents were disposed:
L.S. Lowell W Water _
Sign tur o Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1