HomeMy WebLinkAboutSeptic Pumping Slip - 136 SAW MILL ROAD 3/25/2016 Commonwealth of Massachusetts
u City/Town of KEGEI
System Pumping- Record'
Form
DEP has provided this form for use-by local Boards of Health. Other form 'May°b6i-V641.15dt the
information must be substantially the tame 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, eft gh se pf house Left/
Right side of building, Left/Right front of building, Left/Right rear of buijoing, Un r= e d 6
...w\
Address
City/Town State Zip Code
2. System owner:
Name*
Address(if different from location)
City/Town ' Stater
�...
Telephone Number
B. Pumping Record �.
1. Date of Pumping pate 2. Quantity Pumped: Gallons r
3. Type of system: El Cesspool(s) [-9 eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑,Y0t ® No If yes, was it cleaned? ❑'Yes "❑ No,
i
" 5 Condition o�fst�e�µm�
`(2::) f C f
6: System Pumped By: I
Nell.Bateson F5621
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
al S'. Lowell Waste Water
Sign t e Haule Date
t5forrM.doc•06/03 System Pumping Record+Page 1 of 1
Commonwealth hu tt
x City/Town of
System Pumping Record
Form 4,
UEP has provided this form far 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 g g o �-, g de of ho us
5e, Left
Right side of building, Left Right font of building, Left Right rear of building, Unde -
/
. deW "
Address
t
�:Va� ''
N am
City/Town State Zip Code
2. System Owner:
",f
Name
Address(if different from location)
CltyfTown State �ZIN ode
Telephone Number
B. Pumping ec®r
1. date of Pumping date 2. Quantity Pumped:
Gallons
3. Type of system: ® Cesspool(s) E3-Septic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? es ❑ No if es, was it cleaned? s ® No
. y ®des�
5. Condi'on of System:
( ."
6: System Pumped By: .._.... � •�
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo at' here contents were disposed:
G L S. Lowell Waste Water
Sign t e hlaule Date
t5form4.doc•06/03 System Pumping Record>Page 1 of 1
Commonwealth of M ohus ED
City/Town of
a System Pumping Record
Form 40il i i.0 uu4u
H,EALTH DEM IT
BEP 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 farm 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 /I righ !6��ofhous�� Left/
Right side of building, Left/Right front of building, Left/Right rear of b lding, U►rd
Addres
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zi Cade
Telephone Number
B. Pumping Record
1. Cate of Pumping Date ntity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® es I f yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati®',Why re contents were disposed:
Lowell Waste Water rr
Sign toe Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
PO a - SYSTEM P �NCY RECORD
Commonwealth of Massachusetts (��� ,W.
Massachusetts '-
AA ,N0FZT'H ANDOVER
StB�'l rlt in Rec r—ad �r�r: �����F ou�r n°t° nr .
r
ystem Ration
ysie a weer (wti, cM .r
i
T`rpe: Emergency ❑ Rautine
[] S( tic Tank; No ❑ Yes ((�/
Cessp< ol: No ❑ Yes p .
Date e. :� Pumping:
QuantiN Pumped: 1,5� . gallons
.a'' Pertrlit ^:
S`�stei:: Pumped by (Company); _.
Conte AS transferred to:
Cont: ,jts disposed at,
C�atr
'7` Pumper Signature
Condition of systemJother comments,
k—d
pEP MPROVID FQAO1 I:I07/9S '