HomeMy WebLinkAboutSeptic Pumping Slip - 23 FOREST STREET 4/12/2016 Commonwealth ®f Massachusetts
= City/Town
o Pumping.
Form 4
DEP has provided this forrri 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,6e /Right ear of hous.�, ft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig" rear�f building, Under deck
Address
City/Town State W
2. System Owner: ?
M AY
Name �. Wtiq
Address(if different from location)
Ci frown '
tY State Zip Code
f _ 6 4,
Telephone Number
B. f
Pumping Record �
1. Date of Pumping Date v e 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? Yes ❑ No,
' 5. Condition of System:
.. ,. o(,W y,
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
,.L S: Lowell Waste Water
SignAtufe qt Haule Date
e�
t5form4.doo-06/03 System Pumping Record«Page 1 of 1
Commonwealth Of Massachusetts a,., RECUVEc mw,
City/Town O
M
System in Record "�I
s
fi
M yu .. VW'4 �Form 4 P
o P1 qq '..
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 hous , L Rig ar e of h e, 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 Sta "yde„
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 present? ET Yes ❑ No If yes,was it cleaned? 'Yes ❑ No
5. Conditio of yst I..
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo tion-W er contents were disposed:
G.L S. Lowell Waste Water
Sign toe I Haule Date
t5form4.doc-06/08 System Pumping Record•Page 1 of 1
REC IV
....
Commonwealth of Massachusetts CL
City/Town ®f /41� 7 Nil)
System Pumping Record 0
gFt
TOWN FOFMATH ANt)OV']
IL , W" �r
Form 4 HEALTHDEPARTMFNT
............
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-Locjati�'o'n- Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of_hhowe, Right rear of house. Left rear of building. Right rear of building.
Address-
-SA-
City/Town State Zip Code
2. System Owner:
Name
-Address(if different from location)
-City/Town Stat Zip Code
Telephone Number
B. PumpingRecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ 'Sepiic Tank ❑ Tight Tank
F-1 Other (describe):
4. Effluent Tee Filter present? 0, -lies ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc7ati aw'1er 7 contents were disposed:
o.L D /9 Lowell Waste Water
qlgr1p6tu e of Haul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth f Massachusetts �.�,� ,
City/Town of S
System D "i ., o 0
o
DEP has provided this form for use by local Boards of Health. Other fo :may"be use;"but thd"
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 1. Sys em La alio : ,
forms on the �c
computer, use
only the tab key Address
to move your
cursor-WI
use the return City/Town State f Zip Cade
key.
2. System Owner:
vlu
Name
rewn Address(if different from location)
City/Town State/�1 IL6=' "�)
Telephone Number
B. Pumping cIr
1. Date of Pumping 2. Quantity Pumped:
Datte o 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? es ❑ Na
5. Condition of System:
n L) ,-, 1 , c .
5. System Ptimpea By:
Name Vehicle License Number
Comp y..
7. Locatio her contents w7 e Isposed:
Signatur of au(Ar Date
t5form4.docm 06103 System Pumping Record o Page 1 of 1