HomeMy WebLinkAboutSeptic Pumping Slip - 767 JOHNSON STREET 4/8/2016 Commonwealth of Massachusetts
City/Town of
N
System Pumping-Record
Form 4
; �v'j
DEP has provided this form*for use;by local Boards of Health. Other forms may be'used, but the
information-must be substantially the tame 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 housk,'Ce
rlght�side®f house;,Left
Right side of building, Left Right front of building, Left Right rear of building, Undil� 6-c-F
Address
City/Town State Zip Code
2. System Owner:
Name*
Address(if different from location)
CitylTown State t Zip Cade
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z QuM,,"Oty Pumped:
Lallans Y
3. Type-of systern' ❑El Cesspool(s) 0--&e�tic Tank Ej 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:
Nell Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locat16n W, contents were disposed:
Lowell Waste Water
'7
Sign itufe 9f Haule4j Date
t6forrM.doc•08/03 System Pumping Record Page 1 of 1
C.ornmonwealth of Massachusetts � ❑ W❑o
city/'rown of NO. ANDOVER
System Purnping Record
Orr rorr rt r� ��
t } DEP has provided this form for use b local Boards of Health. Other tot sit❑ ����'tr;T�ut the
information must be substantially the same as that provided here. Before, using this foram, 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 1. System Location:
forms on the
computer,use 767 JOHNSON ST.
only the tab trey Address -
to move your NO. ANDOVER MA 01845
cursor-do not — ----- ------ - - - ... ........ ........
use the return City/Town State Zip Code
key. 2. System Owner:
JOSEPH DIFRAIA
Narne
- /Address(if different from location)
— ....._ - .........................
City/Town State Zip Code
- — ........_. _....
Telepl7ane fVrm7l>er -
B. Pumping Record
1. Date of Purrtrp1179 Date 10/9/09 _ _ Quantity Pumped: 1500 Gallons
:3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): _ ------
r
4. Effluent Tee Filter present? ❑ Yes ❑ It yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Benjamin Shute H79 406
Name Vehicle License Number
J's Septic& Drain
Company
7. Location where contents were disposed:
CLSD
ell
0/9/09
gnatur ' f t-Iauler Date -
t5formzt.doc•06/03 System Pumping Record-Page 1 of 1