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HomeMy WebLinkAboutSeptic Pumping Slip - 50 ROCKY BROOK ROAD 4/7/2016 �� Commonwealth Of Massachusetts � City/Town Of t n Y tem i n Record 1 i 1I e Form 4 � DER has provided this form for use-.by local Boards of Health:[Otter form's may be'us6d, 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 house, Left/�i ht tilde of house Left/ Right side of building, Left/Right front of building, Left/Right rear of buildinggn °" r rt<- Address City/Town _j Skate Zip Code 2. System Owner: Name Address(if different from location) City/Town ' State' Zi , Telephone Number %�"• B. Pumping Record 5 -1...� w 1. Date of Pumping Date 2. Quantity Pumped: Gallons F 3. Type of system: ❑ Cesspool(s) C316epfic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No 5. Condition JSy tem: 6. System Pumped By: Nell Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca 'ort.. here contents were disposed: C t-10.Q Lowell Waste Water Signkufe qf HauleV Date t5form4.doc•06/03 System Pumping Record Page 1 of 1 III IIII ' e...W ^ Commonwealth Of Massachusetts p � �e C ity/Town ®f f , �e ystem Pumping Record Form 4 m�^ rirl�:rl i4c�im�C1i ^i�IX Via DEP has provided this form for use by local Boards of Health. Other form may ay 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 Important: y __ When filling out 1. System Location: Left front, left rear, left side of house. Right front, right rear,.riight side of hous forms on the ° computer, use _ only the tab key Address — q to move your cursor-do not � use the return CitylTown State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town State Zip Code ? 7 =" Telephone Number B. Pumping Record 1. Date of Pumping — 2. Quantity Pumped: v � Date Gallons 3. Type of system: © Cesspool(s) — eptic Tank E] Tight Tank Other(describe): --- 4. Effluent Tee Filter present? 0 Yes o If yes, was it cleaned? p 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. .w Lowell Waste Water .- - -- igna ure of H Or Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts w City/Town of System Pumping r Form 4 DEP has provided this form for use by local Boards of Health. Other fo 4'sp ppf information must be substantially the same as that provided here. Bef a ur�g this fry ,.,th your local Board of Health to determine the form they use. The System Pumping ecord muse be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: r forms an the ti� .� ., computer, use - - - ( : y only the tab key Address to move our ,� . ?" �,. . •. cursor—do not City/Town State Zip Code use the return key.Y 2. System Owner: & 6M Name - - Address(if different from location) City/Town Statrt F°° Zip Code Telephone Number B. Pumping coy 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ❑" epfiic Tank ❑ Tight Tank ❑ Other(describe): - --- 4. Effluent Tee Filter present? [ Yes a....... If yes, was it cleaned? ❑ Yes ❑ No System: �,.., 5. on ItI n a.� 6. Systetp Pum By: Name Vehicle License Number Company .� — ---- 7. Location W �Te contents werposed: w SignaturerH_p061l Date t5form4.doc^06/03 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts City/Town of I System in r �r , f; F �a .° Form 4 'ly yv. 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 filling out 1. System Location: µ.w forms on the computer,use C.. only the tab key Address —to move your cursor-do not use th&return Citylrown State �— Zip Code ,key. 2, System Owner: , ''(A Name i Address(if different from location) -- -- — ----- CitylTown State - -- Zip Code Telephone Number — B. Pumping Rec6rd 1. Date.of Pumping gate 2. Quantity Pumped: — Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): -- .r 4. Effluent Tee Filter present? ❑ Yes w No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By ; Name Vehicle License Number Company 7. Locatio vuhere contents were djsed: �. ff C +� t . pate `\` Sign ure ti taler - — — - http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4,doc-06/03 System Pumping Record•Page 1 of 1