HomeMy WebLinkAboutSeptic Pumping Slip - 475 WINTER STREET 3/28/2016 Commonwealth f Massachusetts
H i Own of 1
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Y
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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: