HomeMy WebLinkAboutSeptic Pumping Slip - 45 FOREST STREET 4/12/2016 Commonwealth of Massachusetts
City/Town of
System Pumping- Record
Form 4
DEP has provided this fora 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: Lett/Right front of hous , e " Rig ear *rear , Left/righ id6 of house Left/
Right side of building, Left/Right front of b i1 Ing, Left/RIg of building, Un er eck
Address
Cityfrown State Zip Cade
2. System Owner:
Name'
Address(if different from location)
Citylrown ' State __ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons -`
3. Type•of system: E] Cesspaol(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
' 5. Condition of Syste :
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ere contents were disposed:
PL S. Lowell Waste Water
._..
SignAtu I Fe9tHaulev Date f
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City own of `
System i C d ., `'.
Form 4 r v
�� tt� /t �i'�r f ;»t i•.i(
DEP has provided this fora far use=by local Boards of Health 'Of b u ed;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 Le Righ ar of hous Left/right side of hawse, Left/
Right side of building, Left!Right front of building, Left/Right rear of building, Under deck
Address L" G f V4. !
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State Code
Telephone Number
_ r
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? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System m / V\
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GL-S. Lowell Waste Water
6aA ,.Oc
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
v v„
Commonwealth of Massachusetts
u City/Town of
p
System Pumping r d O i ir::fi�i i Pi ui)(W: R
„ v in1 r °I Form 4 m,2
,
Sy v
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 Li)/Right -ar of A our
Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
1-15 T o(-eed-
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
�tJ C) `,`
Telephone Number
B. Pumping Record
1. Date of Pumping r l ` 2. Quantity Pumped: � '�
Date ,/I 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:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wher contents were disposed:
.>...a...,.� r-
G.LS.P Lowell Waste Water
j l r
Sign toe cfHauleV Date
t5form4.doc^06/03 System Pumping Record^Page 1 of 1