HomeMy WebLinkAboutSeptic Pumping Slip - 130 MARIAN DRIVE 7/23/2012 Commonwealth Of Massachusetts
_ City/To
wn o f
Y' tem Pumping rd
Form 4
DEP has provided this form i for uses 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 house, Left/ t 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 °
City/Town State Zip Code
2. System Owner:
Name
c:). M
Address(if fent from to tian)
`
City/Town State `. Zip Code
t
. "
Telephone Number
B. Pumping Record r^
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? ® ep ❑ No If yes, was it cleaned? [ --mss ❑ No
5. Condition of Sys m,
C .
6. System Pumped By.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-whe contents were disposed:
C L S.'P Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
City/Town of
Pumping System
Form 4
1'0'�VN 0I NOR71-1 AN00V-.`jFR
DEP has provided this form'for use by local Boards of Health. Other ri r�
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, Lefty rear of hous4�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 �. � 'M°._��, ry ��. ..�..�......_. ....Mate �, '�.., Zip Codes. „�- 411-
P
2. System Owner:
Name
Address(if different from location)
Cityrrown State L( Zip Code
Lit r!. � j
Telephone Number
B. Pumping Record
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? ❑ 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:
Lowell Waste Water
Sign toe I Haule Date
t5form4.docr 06/03 System Pumping Record•Page 1 of 1