HomeMy WebLinkAboutSeptic Pumping Slip - 72 PATTON LANE 3/21/2016 Commonwealth of Mas'sachusetts RECEIVED
City/Town Of
System Pumping, Record
Form 4 H�E���r V F11.
4i~lr�U i Ui I'N),'I COU41�
DBP 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.Facility. Infer tin
1, System Location: Left/Right front of house, Left/ hfi rear of houses, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/ ig rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' State Zip Code
Telephone Number
B. r
Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons a
3. Type of system': ❑ Cesspool(s) ® p—is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑-"h ..., If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste :
6. System Pumped By:
Neil.Batesbn F5321
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location•v�here contents were disposed:
L S. Lowell Waste Water
Sign t e Houle Date
t5form4.docd 06/03 System Pumping Record Page 1 of 1
Commonwealth f Massachusetts
City/Town of
System D AUG 1 1`31
Form
�V/ � 7
DEP has provided this form for use by local Boards of Health. Other forms'may b 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 bmitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. Syste Location:
forms on the
computer, use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner: �j
Name
Address('rf different fro �1&aion)
City/Town State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. T yp e of system: ❑ Cesspool(s) U-peptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name _ Vehicle License Number
Company
7. Location where contentnere disposed:
Sig ate Hauler Date
t5form4,doc-06/03 System Pumping Record®Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System on r r
.4K Form U
DEP has provided this form for use by local Boards of Health. Other fora s(mo !hp'u d,,but the I
information must be substantially the same as that provided here. Before using this form,<check viiitb 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: ...,
When filling out 1. S
forms on the y cation . —
stem Location,
computer, use -
-—
only the tab key Address ".
to move your t Zips Co°
use the return
CitylTown de --
key. 2. System Owner:
VQ
Name —
. . '
n a
Ad resS
if different om oca io
St Zip Cod —
Telephone Nurripe r
�
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 EJ-4 If yes, was it cleaned? ® Yes ® No
5. Condition of ystem: t
6. System ury)ped By:
. ,
Vehicle License Number
-- —
Company -
_ _.°m....
7. Locatiormwhere content .ere sed:
Signa#ur of aul Date
t5form4.doc-05/03 System Pumping Record^Page 1 of 1
Commonwealth Of Massachusetts
mu.
City/Town Of I f
a
System mpin rd AY
Form 4
..�„
®EP' has provided this form for use by local Boards of Heafth: Thd System Fumrpinig Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
p Location-
forms � .e
n t use t 1. System d ,.... �
computer,
cursor edo not your
Address
y
use the return City/Town Mate Zip Code
key. 2, System Owner:
Name - - — —
�°"' Address(i(different from—location)
- --- -- --
Ci ------— Ste Z
— -- --
t (Town e i Code
y -- ...
Telephone umber
13. Pumping Record
1. Date of Pumping pate - 2. Quantity Pumped: - -
ris
3. Type of system: Q Cesspool(s) F] peptic Tank ❑ Tight Tank
❑ Other(describe) – -- -- -
4. Effluent Tee Filter resent?
p F1 Yes Ej°°"No If yes, was it cleaned? E] Yes ❑ No
— y stem:
5. Condition of S
f ..
6. System m Pumped
---------- --
:Name ' r Vehicle License e Number
p , a -- - —
Com a y.�
.7. Loca loll where contents were disposed:
w, K 4
Sig atu e f auu er � �
_ --
date
http://www.mass.gov/dep/wat'r/approvals/t5forms.htm#inspect
t5form4.doc>06103 System Pumping Record•Page 1 of 1
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