HomeMy WebLinkAboutSeptic Pumping Slip - 344 RALEIGH TAVERN LANE 4/4/2016 x
n
aCommonwealth of Massachusefts
Cit�/Town of
System Pumping Record
Foy
yM'b
CEP 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 farm, 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 Le +righid�of house, Left/
Right side of building, Left/Right front of building, Left/Right rear Of bul ding, Under
Address
J�Lj- O*Ao-A
Cityfrown 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:
�aAons q
3. Type of system. Cesspool(s) pfic lank ® light Tank
Other(describe):
4. Effluent Tee Filter resents
p ep D No If yes, was it cleaned? —ei-d No
5. Condition of ystem: Q
r
"JQ_,
6. System Pumped Sy:
Neil Sates®n F5821
Name Vehicle License Number
Sateson Enterprises Inc
Company
7. Lo on-wh re contents were disposed:
-- -,.
GL S. Lowell Waste Water
Sign t e Houle Date
t5form4.docm 06/03 system Pumping Record d Page 1 of 1
Commonwealth of Massachusetts
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System Pumping Recordi ... 12,
Form 4 �qq�'„
E[[�rgll �p� IPCt Ai'6 P N 4i spa W
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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/Right front of house, Left/Right rear of hous righ ide of bewse Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address ` �-f..—•. .
Cityrrown State Zip Code
2. System Owner:
Name �1
Address(if different from location)
Citylrown State Code
Telephone Number
B. Pumping ec 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? es ❑ No If yes,was it cleaned? (j Y ❑ No
5. Condition oSystem:
C .
�. �
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo kW_whiere contents were disposed:
G.L,S.P 11 Lowell Waste Water
4Sign9tufe TfbauleU Date
t5form4.doc^06/03
System Pumping Record d Page 1 of 1
Commonwealth of Massachusetts
ityfTown of
d �
a _ System Pumping Record
Form 4 ,,�,a' d " ?01
�b
DEP has provided this form for use by local Boards of Health. Other for f-
a' t r
information must be substantially the same as that provided here. Befor 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 Locat 'Left sld.._... f "
y e of hous,�,)Right side of house, Left front of house, Right front of house,
Left rear of hour-6°'Right rear of house. Left rear of building. Right rear of building.
---- -- - -------- -
Address µ -
1
-- -- ------- - ---- - — - ----- -
CityrTown State Zip Code
2. System Owner:
Name ---- -- ---- -- --- -- - --
-- - --- - - - -------- - ---- - -
Address(if different from location)
-- - - - ----------- --
City/Town State Zip Code
Telephone Number
B. Pumping ecord
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? ❑ Yes ❑ No
5. Conditi n f System:
r
6. System Pumped By: `
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc _
Company
7. Location_where.contents were disposed:
L.S.D � L ell to Water
- -- — -- ----- --------
Signature o H er Date
t5form4.doc•06103 System Pumping Record o Page 1 of 1