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HomeMy WebLinkAboutSeptic Pumping Slip - 252 GRAY STREET 3/17/2016 IC Commonwealth of Massachusetts a ity/Town of ���` �, % ,Y '�., a Pumping System Form 4 1A, DEP has provided this form for use by local Boards of Healt a °" �`1 vie but the information must be substantially the same as that provided ere°�B°efore°,�n hts,'°f 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: Leftcah front of hou , Left/Right 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 Cityrrown State p\ Zip Code 2. System Owner: Name Address(if different from location) City/Town Statee Zip C die l t Telephone Number B. Pumping Record ry 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? ❑ Yes Rf No If yes, was it cleaned? ❑ Yes ❑ No 5. Cond'tion of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatjon-wFlete contents were disposed: Lowell Waste Water �..___. Sign toe Haule Date t5form4.doc•06/03 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts WWW City/Town of - System umpin cord Form 4 wA, fe"wi O N O NORTH NLIJ LF DEP has provided this form for use by local Boards of Health. Other forms ENT 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 front of house�riglit front of howl left side of house, right side of house, Left rear of house, right rear of house, leftide afmbuilding, right rear of building, under deck. City/Town State Zip Code '�m 2. System Owner: Name -- - — — Address(if different from location) City/Town Stat ip . d – pp �� 1 Telephone Number B. Pumping ec®r � 7 1. Date of Pumping Gate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 0-'Septic Tank ❑ Tight Tank ❑ Other(describe): - -- - - 4. Effluent Tee Filter present? ❑ Yes R. -No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil J. Bateson _ F5821 _ Name Vehicle License Number Bateson Enterprises Inc. _ Company 7. LQc tiorw ere contents were disposed: G.L.S. Lowell WagM Water Signa re f Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth Of Massachusetts u City/-Town Of Farm 4 DEP has provided this form for use by local Boards of Health. Other form may be used, but the information must be substantially the same as that provided here. Before sly �f ' � 1t our local Board of Health to determine the form they use. The System Pumpin an�rtb � mfft d 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 ha ht front of house, �,,,,e...�, Right se, Left rear of house, Right rear of house. Leff rear of building. Right rear of buildlrfg..........._....._._.............._..._._."- Address _ City/Town State Zip Code 2. System Owner: Name Address(if different from location) Cit y!Town p � m�7���..Zi�qade . 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: V- "._ . 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatiqpwbere contents were disposed: L D-� Lowell Waste Water g to a of HaulEur Date t5form4.doc•06/03 System Pumping Record^Page 1 of 1 Commonwealth of Massachusetts _., 't '. City/Town of � System ur in Record ��� � � � .� Form 4. i� Gtt l7ut DEP has provided this farm for use by local Boards of Health. O r�r t t„ 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: ••W-..��. When filling out 1. System Location: Left front, left rear, left side of hous . Right froDtt, fig 'ht rear, right s a of house forms on the computer, use only the tab key Address 4,4AA C to move your cursor-do not use the return City/Town State Zip Code key. _ - 2. System Owner: AvWe.. Name ' Address(if different from location) Cityrrown State/ ip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: Q Cesspool(s) eptic Tank Ej Tight Tank Other(describe): 4. Effluent Tee Filter present? Yes o If yes, was it cleaned? [1 Yes 0 No 5. Condition of System: 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water �Iv ro-j— A 7 igna ure of H u r Date t5form4.doc•06/03 System Pumping Record>Page 1 of 1