HomeMy WebLinkAboutSeptic Pumping Slip - 66 CEDAR LANE 3/22/2016 l;
Commonwealth Of Massachusetts 'r J
City/Town of
x System '
Form 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/Right rear of house(!A/righ side of hczus�, 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:
CAA
Name
Address(if different from location)
Citylrown State , i Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qua City 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. Condi 'on f Syst�em �
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 HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth ®f Massachusetts
L—RECgIVED it y/Town cf
System Forme 4 TOWN OF NOR'rii ANDOVER
DEP has provided this form'for use by local Boards of Health. Oth 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/ ht rear of house ; right Ide of hour , Left/
Right side of building, Left/ Right front of buildih Right rear of bu Ing, Under d cR--
Address
Ci !Town State Zip Code
2. System Owner:
U.
Name
Address(if different from location)
CitylTown State � � p Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi g of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location. when contents were disposed:
L S. Lowell Waste Water
Sign toe I Haule Date
t5form4.doc•06103
System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
w City/Town ®f
System pin r �A`I'.
Form 4 TOWN OF NOR Y1
HEA LI H DEPARTMa NT
DEP has provided this form for use by local Boards of Health. Other forms may"'i'°n§W,- tft""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 front of house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2, System Owner:
Name
Address(if different from location)
City/Town State Zip Code
.._.w_ w..._
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 ❑ Na
5. Condition of System:
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. Ww4 Waste Yyater,
Signature f/„ r 1� ul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
RECEi'VE5""" -
x
City/Town ®f
System u i r w, J�
Form 4
s'r m
DEP has provided this form for use by local Boards of Health. Oth wf r��mayfle usmed, b t
�o� a
m EA1 m u�
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:
When filling out 1. System Location: Left front, left rea , lefts de oust ARight front, right rear, right side of house.
forms on the /
computer, use
only the tab key Address
to move your k, J �
cursor-do not
use the return City/Town State Zip Code
key' 2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping o 2. Quantity Pumped: 0
Date Gafrons
3. Type of system: 0 Cesspool(s) d_ Septic 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:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati -_ ere contents were disposed:
LS. Lowell Waste Water
TX-re of H 4 u r Date
t5form4.doc•06/03 System Pumping Record>Page 1 of 1