HomeMy WebLinkAboutSeptic Pumping Slip - 44 CRICKET LANE 3/29/2016 Commonwealth of Massachusetts
r
City/Town of
Pumping ystem r
Form 4
f i o> ',.
r
DEP has provided this farm for us&by local Boards of Health. 6th r-farin a may b uspda`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/!i6@ rear of house Left/right side of hause, 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 from location)
City/Town ' State ¢
Z�ip�Code
Telephone Number
B. r
Pumping Record
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 ❑ No If yes, was it cleaned? [] Yes ❑ No.
5. Condition of System:
6. System Pumped By: V
Neil Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. jSIgnt w re contents were disposed:
Lowell Waste Water
� 1
Haule Date
t6form4.doc•06/08 System Pumping Record•Page 1 of 1
RECEIVED
Commonwealth of Massachusetts
u City/Town ®f z9UN 2 0113
System Pumping Record HEALTli Dir �
�
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 forrim 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 _
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State i Imo... Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p [ -"des ❑ No if yes, was it cleaned? ❑---Y-es ❑ Na
5. Condition of Sys em: (Ce,
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location,wliere contents were disposed:
�L S. Lowell Waste Water
Sign toe I Haule Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts 1"?,ECEIVED
City/Town of
System Pumping Record
o
Form 4 .... <w�rei�i
M �,mr wr vvm nn nUrzr✓✓r✓ in rm irar.. aara lava
DEP has provided this farm 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 lght rear of ho,to , Left/right side of house, Left/
Right side of building, Left/Right front of building Le - Rig r of building, Under deck
Address ( ,: p
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State �ip Code
Telephone Number /
B. Pumping oc r
1. Date of Pumping Date 2. Quantity Pumped: 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? E] es El No
5. Condition f System: t
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locat n Where contents were disposed:
G.L S Lowell Waste Water
M1
Sign toe HaulerU Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
W pity/Town o�
bystem Pumping rd
Form 1"0 I
DEP has provided this form for use by local Boards of Health�Othjr �r tf� � i� � but the
information must be substantially the same as that provided tfbM.",ffefore,6 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 hour gait rear of h us , left side of building, right rear of building, under deck.
" li ► ' J d
City/Town State Zip Code
2. System Owner:
Name ---- ------ —
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
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? es ❑ No If yes, was it cleaned? a No
5. Condition of System,
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
.L.S. . A, oweIIYMsteWpter
SigVuof ule r Date
t5form4.doc^06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
1
_ City/Town of
System Pumping Record
-- Form 4
T l �� V
DEP has provided this form for use by local Boards of Health. Other f � 1 T
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: Lf fk..sid.e of house, Right side of house, Left front of house, Right front of house,
Left rear of ho Right rear of hotase Left rear of building. Right rear of building.
Address -
City/Town State Zip Code
2. System Owner:
-----------------
- ------ -----
Name — -- ----------
- - ----- — -
Address(if different from location--- )
- ---------- --- -----
City/Town — Sta ii
—: ` - rm i
Telephone Number
B. Pumping eIcord
`~l o
1. Date of Pumping - --- 2. Quantity Pumped: — -----_. -..
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 0,16; ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
G �
6. System Pumped By:
Neil Bateson F5821
Name — ---- - - Vehicle License Number — --—
Bateson Enterprises Inc_
Company
7. Loc icon u1u Fe,contents were disposed:
G.L.S.I Low fl to Water
--- _ ---- ---
Signature f H er Date
t5form4.doc»06/03 System Pumping Record•Page 1 of 1
Commonwealth nwealth Of Massachusetts
it /Town of
System Pumping Record RE,CEIVED
sa�t`
Form 4
DEP has provided this form for use b local Boards of Health. Oth r for {{ ay be used, but
P Y r�f�' ) � e
information must be substantially the same as that provided here. afore uiv
e k with your
local Board of Health to determine the form they use. The System 'mtWU,,, bmitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left front, left rear, left side of house. Right fr r! rigs rea right si
forms on the
computer, use A
to move Y tukey Address (; 44
.. . C � ... ...µ�
cursor-do not City/Town/Town ( )i
use the return y State Zip Code
key. 2. System Owner:
--— Name
Address(if different from location)
City/Town State, Zip Code
-
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) -- eptic Tank ® Tight Tank
Other(describe): --
4. Effluent Tee Filter present? __ es L] No If yes, was it cleaned? Yes [1 No
5. Condition o System:
6. System Pumped By:
Neil Bateson F 5821 _
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location W—be ,contents were disposed:
fS.D Lowel I Waste Water
e of H u r Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
Commonwealth f Massachusetts �,P�E" 'G'- E',�v a „
City/Town of
System Pumping Record JUN () 9 2008
Form
DEP has provided this forrn for use by local Boards of Health. Other forms,'mby be u'§6d,-"bW—th
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 I. System Location: � .ter ...._,.. °..."�
forms on the - ,,•
computer, use a ..., , .a ._. ( 7,
only the tab key ddress f�..� ^ �. �
to move your yL � G �.` .
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
VQ Name - --
reun Address(if different from location)
City/Town States ... Code
6
Telephone Number
B. Pumping con
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑tl""Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? ,µ ❑ No If yes,was it cleaned? ["'"Yes .,
p ❑~`Yes Cl Na
5. Condi'on of System �xm..� ",.�. ,,, f�.
6. y m B
Name N Vehicle License Number
Company
7. Lacati yvhere con,t nts
e disposed:
Sign*r%d li Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City/Fown of I
System Pumping coy
Form 4
Y 4�4 i�y,Po
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information ---- - --
Important:
When ruing out 1. System Location:
forms on the
computer,use
only the tab key Address - — - - --- - — --
to move your 111
_.w ':✓
cursor-do /
not -
Cit Town `° — -- - � � -----� --- � ---- - --
use the�return City/Town Zip Code
key. 2. System Owner:
Name — — -- — - — -- ---. - —
-
Address(if different from location)
City/Town State Zip Code'— --- -- -
Telephone Number --- -- -
. Pumping Record
1. Date.of Pumping -- — 2. Quantity Pumped: —
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑, eptic Tank ❑ Tight Tank
❑ Other(describe): - — -----------
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? E] Yes ❑ Na
5, Con,d tian sf
6. System u ped By.:
a.
Name = Vehicle l icense Number
Company
7. Locatio here cont s, we isposed::
r
S.„, - .✓1 N'^ wM. exiw/' rum .. ..,d` "` --. —
Signat o a er bake —
http://www.mass.gov/dep/wa er/approval8/t5forms:htm#inspect
t5form4.doc-06/03 System'Pumping Record<Page 1 of 1