HomeMy WebLinkAboutSeptic Pumping Slip - 475 WINTER STREET 3/28/2016 Commonwealth f Massachusetts H i Own of 1 ' tern i � r Y � Form 4 p y k t ��aa'r ,,,,,,,., DEP has provided this form for us&b 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: Le�"�I`ght front of house;.Left/Right rear of house, Leff/right side of house, Left/ Right side of buildingl,left RR fight f❑6f building, Left/Right rear of building, Under deck Address rp City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stat Zip Code Telephone Number �< B. Pumping Record w 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? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No. 5. Conditi n q System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc company 7. Lo ore contents were disposed: G L S. Lowell Waste Water l TKIMA LK Sign t e Haule Date t5form4.doe-06103 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping c r 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 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. Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stat 2"'" IC�Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Eg-, eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes D'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ���.�:/� 4 - .� 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc, Company 7. Locat' where contents.were disposed: L.S. Lawell ste ter E tt Signa u of a uler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 m Q Commonwealth ®f Massachusetts City/Town of a System Pumping Record a ,0 Form 4 j�,N�. DP provided this form Boards Oh a � t e f �information must be substantially the same asthat provided here. " k with your local Board of Health to determine the form they use. The System umping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: „_,..., r „ When filling out 1. System Locatio '"Left f�roritft rear, left s of houseRight front, right rear, right side of house. forms on the "� computer, use only the tab key Address 9 y l / , to move your1 cursor-do not City/Town State Zip Code use the return key. _ 2. System Owner: V6_ -- - Name Address(if different from location) Cit !Town State Zip Code Telephone Number B. Pumping ecor 1. Date of Pumping Date Quantity Pumped: Gallons 3. Type of system: p Cesspool(s) _ eptic Tank Q Tight Tank 0 Other(describe): -- 4. Effluent Tee Filter present? Ej Yes No If yes, was it cleaned? El Yes No 5. Condition(of System: / 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: .L.S.D Lowell Waste Water igna ure of H u r Dafe 1 t5form4.doc>06103 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts . � . _ City/Town of System Pumping Record Affl� 6 s _ w Form DEP has provided this farm for use by local Boards of Health. Oth6r,forms- may"tam,u "`but4he 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. Syste Location: forms on the computer, use ---- - ------ --—------- - -- — - - — only the tab key Address .. ' f A, , .. to moue your -- -- cursor-do not Crtyffown Zip Code use the return key. 2. System Owner: , . Name - ---- --- - Address(if different from location) - ' Zip Code CitylTown - Sta B. " ..... .t. Telephone Number Pumping c®r 1. Date of Pumping -sate 2. Quantity Pumped: Gallons - - 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): - - - - — 4. Effluent Tee Filter present? ❑ Yes ❑" If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: n 6. System P m d day: we - `` Vehicle License Number t Company 7. Location here contents,�veisposed: - CA Signat a ler Date h f t5form4.doc•06/03 System Pumping Record>Page 1 of 1 FORM 4-SYSTEM PUMPING RECORD SEPTIC IN SERVICE � 107 FOREST STREET; MIDDLETON,MA 01949 (978) 774-2772 COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: SYSTEM LOCATION: i 0 DATE OF PUMPING: /U'-Z QUANTITY PUMPED: GALLONS CESSPOOL: NO YES 0 SEPTIC TANK: NO YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: ��� INSPECTOR: