HomeMy WebLinkAboutSeptic Pumping Slip - 45 CRICKET LANE 3/17/2016 Commonwealth of Massachusetts w,
City/Town of
c Pumping Record p /� r W r"..
Form 4
DEP has provided this form for usetby local Boards of Health. Other form '(ha be�usd,�but°tie
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 1 ht rear of hoes"; Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address +
OU
.
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown ' Stat Zip,Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system, ❑ Cesspool(s) In Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No.
�
U
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location vvhe a contents were disposed:
Ca.L S, Lowell Waste Water
Sign t e kaule Date
t5form4.doce 06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System i
Farm 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
1. System Location: Left/Right front of house, Left�R i t rear Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
`-L ' ( 1, ('(
Address
City/Town State �. „„Zip Code.
2. System Owner:
Name
p
Address(if different from location)
City/Town State Zip Code
r .. 42 r
Telephone Number
B. Pumping Record
1. Date of Pumping j 1 " 2. wuantity Pumped: ` 6
Date Gallons
3. Type of system: ❑ Cesspool(s) 0XSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: I
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.L:SIP'I Lowell Waste Water
Sign toe cf Haule Date
t5form4.docd 06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
� 1
City/Town of
System Pumping r
a
Form 4
_w
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: .
forms on the 1 System !�
When filling out em Lacation:
y � --- —----
computer, use -- - 0
only the tab key Address
to move your
cursor-do not City[Town Stat Zip Code
use the return
key. 2. System Owner:
VQ Name
Address(if different from location)
cityrrown St Zi Code
Telephone e Number
— --- — --
p
B. Pumping c®r ....
1. Date of Pumping gate — --- 2. Quantity Pumped: Gallons - —
3. Type of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: V
°�
M
6. System P mped By: �
sti
Name Vehicle License Number
Company
contents w re dis os d:
7. Location w r�come >
Signature of I Date
t5form4.doc•06/03 System Pumping Record^Page 1 of 1