HomeMy WebLinkAboutSeptic Pumping Slip - 731 WINTER STREET 3/28/2016 _ \ Commonwealth Of Massachusetts
City/Town Of
System Pumping r
Form 4 ?l J N
4
DEP has provided this form for use by local Boards of Health. The Sy tem,Pumping Rep u t
be submitted to the local Board of Health or other approving authority
A. Facility Inform.atiorl — —
Important:
p en m g out t —y m C�a�
tion form on the
computer, use
— — —
cursor
�donat — - �J .( .. ......, � .C. . °°°
only the tab ke y Address Lk--(&
to use the�return Cityrrown -- --- - State --- — Zip Code - - - ---
key.
2. System Owner:
VQ
Name --- _
Address(if different from location) — -- --T --
— -- — --
CityFrawn — — ----
State ,/"� r°� Zip ode
Telephone Number ---
Pumping Record 12 -
1. Date.of Pumping Date 2. Quantity Pumped: -----
Gallons
3. Type of system: ❑ Cesspool(s) ❑°" eptic Tank ❑ Tight Tank
❑ Other(describe): — ------ ----------__--
4. Effluent Tee Filter present? ❑ Yes Q,,'N If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S ste "
Y � �
6. S--s�te P r,
�rnp ed y;
`( —ww a
vehicle License—N—um—be—r—Name � — -- -----
Company
7. Loca fi,h ,re c e dis sed .�
q
w,
Signature Hai er — Date -- -- —---- —
http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Re.I cord•Page 1 of 1
TOWN OF
U
SYSTEM T N G E
DATE: (-O
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
-R '
DATE OF PUMPING: QUANTITY P ED : 60 GALLONS
CESSPOOL: NO YES SE IC T : NO YES
NATURE, OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION 14ULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOT'S LEAC HF IELTD RUNBACK
EXCESSIVE SOLIDS FLOODED _
SOLIDS CARRYOVE R OT E R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFE RRED TO:
Commonwealth of Massachusetts
Massachusetts
System Pumping Recur
System Owner System Location
(ki 1 Lk,4,- ,
Date of Pumping: - °� Quantity Pumped: ° gallons
Cesspool: No Yes U Septic Tank: No Yes/Vi
System Pumped by: FctreQoet dr ' " License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector: