HomeMy WebLinkAboutSeptic Pumping Slip - 295 REA STREET 4/5/2016 1�1111,`11"' V Hf,")v
Commonwealth of Massachusetts
City/Town of
S ' tern Pumping Record
YS
For 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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility, Information
1. Right side of build System Location: Left/Right front of house, Lefr-
Left Mght-rearpfhouse, Left right side of house, Left
ing, Left Right front of building, /Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cilyfrown State,) Z* C
%,ode
Telephone Number
B. Pumping Record
1. Date of Pumping Date r-. %qua ntity Pumped Gallons
3. Type of system. ❑ Cesspool(s) 0--Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? M`-Yep ❑ No If yes, was it cleaned? E"Yes ❑ No,
6. Condition of System-
-A-D� VA
6. System Pumped By:
Neil Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
-company
7. Locatop-where contents-were disposed:
GLIS Lowell Waste Water
I
4n Haule
Sig t e Date
t5form4.doc•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/Right front of house, Left/ tight rear of hour, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/ ig f rear of building, Under deck
Address 1
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stag �ro "Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Canons
3. Type of system- ❑ Cesspool(s) a eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? Yes ❑... y ❑ Yes ❑,,,.
- p No If es, was it cleaned? No
5. Conditiorh ofPystem: "
6, System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location re contents were disposed:
G L Q Lowell Waste Water
ff raA
SignAtufe qt Haule Date
t5form4.doc•06/03 System Pumping Record a Page 1 of 1
ommonwealth of Massachusetts RECEIVED�.
C ity/Town of �p
System Pumping Record
� w 1wt tMl Oi hBO f" ���D�
Cd�k" III
Form 4 HEi� i 1 D PAR
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 M -ght rear of ho�4A, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/WigYt i ar of building, Under deck
Addressor fie
kv
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
" " ... Zip Code
City/Town Statq�
Telephone Number
B. Pumping Record
s
1. Date of Pumping Dat e Gallon
2. Quantity Pumped: s
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
��� ,„, �,�"(,,.,✓` -mss
Other(describe):
4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7, Locatignh�re contents were disposed:
Lowell Waste Water
Sign to a Haule Date
t5form4.docr 05/03 System Pumping Record a Page 1 of 1
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