HomeMy WebLinkAboutSeptic Pumping Slip - 123 MARIAN DRIVE 3/16/2016 Commonwealth ch u tt
City/Town O
n System Pumping Record
Form 4
®EP has provided this form for use by kcal 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 Mg re�ofh�q Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address
City/Town State
2. System Owner:
Name
H Ain°i1
Address(if different from location)
Cityrrown ' Staten Code
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 ❑ No If yes, was it cleaned? F es ❑ No
5. Conditi n of Syst II r
6: System Pumped By:
Nell Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where.ccontents were disposed:
Lowell Waste Water
Sign t e ct Haule Date
t5form4.doc<06/03 System Pumping Record•Page 1 of 1
Commonwealth Ith Of Massachusetts
W City/Town of
System un pin Record � � a
�¢K Form
` T� tMFUH ANDOVER
DEP has provided this form for use by local Boards of Health. mad, 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, Lefl t rear of hou_e,-Loft/right side of house, Left/
Right side of building, Left/Right front of building, Le 7 `kj`H rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State ip.,„Code
Telephone Number �6
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped;
Date 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? ❑—Y66”❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio�� ' re contents were disposed:
G.L S. Lowell Waste Water
Sign to a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth f Massachusetts r���,��+
u City/Town of
a stern Pumping Record y �c;: << xr Vtrr i �Fr14�1 �: i
Form 4 il�� r
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 farm 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�Rjght rear of how; , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left%Iigfit rear of building, Under deck
Address -y
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State ,.., p
de
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) E3 "Septic Tank ❑ Tight Tank
❑ Other(describe);
4. Effluent Tee Filter present? es ❑ No If es, was it cleaned? Yes _... .. ."
Y ®` � No
5. Condition of System:
6. Sysm 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•06/03 System Pumping Record a Page 1 of 1
Commonwealth Of Massachusetts
v City/Town Of
System Pumping rd RECEIVED
Form) 4 f
�A, yylyr f n�Nf
DEP has provided this form for use by local Boards of Health. Other fo s may be used bu t
information must be substantially the same as that provided here. Befo 6T th your
local Board of Health to determine the form they use. The System Pu [tied to
the local Board of Health or other approving authority. =4iq
A. Facility Information
1. System Location.Left front of house, right front of house, left side of house, right side of house, Left
rear of hou ;right real of douse ft side of building, right rear of building, under deck.
�%'�-�`� �--C../�. . .-- �Jam. /, ,�'",✓�c: �,� � .._ ,�%'
City/Town State Zip Code
2. System Owner: /
Address(if different from location) — -
City/Town State -
Telephone Number
B. Pumping ecor
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? ❑°des ❑ No
c
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc. _
Company
7. Location where contents were disposed:
L.S.D. owe[ aste W er
Signature of ul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
Pumping System r
Form 4
DEP has provided this form for use by local Boards of Healt er orms may be used, but the
information must be substantially the same as that provideder "Before using this form, check with your
local Board of Health tQ determine the farm 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 side of house Right side of house, Left front of house, Right front of house,
Left rear of house, i t rear of house;,Lift rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner:
----------- -
Name -- -
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2.,Quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): --
4. Effluent Tee Filter present? F Yes No If yes, was it cleaned? ® Yes ❑ Na
5. Condition of System:
--
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterp rises Inc__
Company
7. Location where contents were disposed:
Lowell Waste Water
Signature of auler Date
t5form4.doc•06/03 System Pumping Record>Page 1 of 1
Commonwealth of Massachusetts
City/Town of
Pumping System r
Form
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
Important:
y Location:
When ms oin the
out 1. System .
computer, use (1 "
only the tab key Address C' . r C.:w µ -'= �.k"
to move your �`�� ` . `5 V )-yam. � �c°""�,-�.�.• -"."a (�--,�-_-.....
cursor-do not City/Town Stat6 Zip Code
use the return
key. 2. System Owner:
VQ Name
ream Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping ec r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) a'geptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? f D Yes ® No If yes, was it cleaned? a"-Yes ❑ No
5. Con itlon of S s m'
r-z s
6. Systerp P mped_.By' '
W �
Name V icle License Number
Company --
7. Location wllp�re content wen posed:
////(C
signature of u Date
t5form4.doc^06/03 System Pumping Record m Page 1 of 1