HomeMy WebLinkAboutSeptic Pumping Slip - 1440 SALEM STREET 3/25/2016 Commonwealth
City/Town of :.pd X015
System Pumping-Record
Form 4
DEP has provided this form for us&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. Infr ti®n
1. System Location: Left/Right front of house, Left/of rear o
y g f house; Left/right side of house, Left/
Right side of building, Left/ Right front of building, Left TR g` h rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State 71 Gde
Telephone Number
B. Pumping Record
i µ S , l y .
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
r
3. Type of system*- ❑ Cesspool(s) ❑ a'p is Tank ❑ Tight Tank
❑ Other(describe):
p ®��°°Y ❑ No If yes, was it cleaned? ❑,°Y6s��.-°...-'
4. Effluent Tee Filter resent' e ®
No
5. Con ition-of Sy tem
.
6: System Pumped By
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatijort,vher contents-were disposed:
C
L,S. . / Lowell Waste Water
Sign t e cf,iaule Date
t5form4.doce 06/03 System Pumping Record Page 1 of 1
Commonwealth f Massachusetts
City/Town of
Pumping System
4
Form 4
s
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, Left/right side of house, 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:
Name
Address(if different W locations 1
Cityrrown ' q r �� State . Code
i .,..
Telephone Number �
B.
Pumping Regard
1. Date of Pumping 2. Quanti Pumped:
Date ty p Gallons
S. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? Ye ❑ No If es, was it cleaned?
present? � Y [�J-Yes ❑ No,
' S. Conditia of SY stem
c
6. System Pumped By.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L'S > Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/08 System Pumping Record«Page 1 of 1
Commonwealth Of Massachusetts
z
City/Town of t
a Pumping
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 Alf1j, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left%Right rear of building, Under deck
Address
r
"�t0 .-
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
H$ _
Telephone Number
B. Pumping Record
1. Date of Pumping ` "' 2 uantity Pumped:
Date 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? es —1 No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo a)igr1"wiere contents were disposed:
Lo
L S. Lowell Waste Water
Sign toe f HaulerU Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
- - City/Town of
System Pumping Record Form 4 TN ���n NOR��I ANDOVER Form
HEAL rH DEPARTMENT
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 tQ 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 side of house, Right side of house, Left front of house, Right front of house,
Left rear of hous Right rea
r of house. Left rear of building. Right rear of building.
--
Address / i 4q �
City/Town ( i State Zip Code
2. System Owner:
Name -
- --- - - -
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping etcord - --
1. Date of Pumping — - - 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) 019epfic Tank ❑ Tight Tank
❑ Other(describe): --- -
4. Effluent Tee Filter resent?
p Yes ❑ No If yes, was it cleaned? "s❑ No
5. Cond'tion of Syst
- - - -- ? -
6. System Pumped By:
Neil Bateson _ F5821 _
Name Vehicle License Number
Bateson Enterprises Inc
Company —--- —
7. Locatic7n-w ere contents were disposed:
G.L.S.D ow Was e Water
Signa r H uler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
W
City/Town of �System umpin c rd ������ � ° 011
k Form 4
L"RIECEIVERD N OF N RTH ANDOVER=°Aw T DE.RAT NT
DEP has provided this form for use by local Boards of Health. Other for "
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.:.L:eftfront ofaouse, right front of house, left side of house, right side of house, Left
rear of hod s6, right rear of hpuse 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 Stater —Zip Code
Tel❑❑ __'"°."'
phone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [a"" eptic Tank ❑ Tight Tank
❑ Other(describe): - -- - --
4. Effluent Tee Filter present? E]-Yes No If yes, was it cleaned? es ❑ No
5. Condition Syst yy
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locaton;whre contents were disposed:
6=L D,_ ejoWaste
. m
Signature o H 4er Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1