HomeMy WebLinkAboutSeptic Pumping Slip - 28 JERAD PLACE 4/21/2016 Commonwealth u
City/Town of .
Pumping,System r
Form 4
DEP has provided this form for use:by local Boards 6 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. Infer tion
1. System Location: Le h#frntofh
Right side of building, Left I Rfr t fr� ou b Left/Right rear of house, Left/right side of house, Left/
�,, o c�us
g g, h ni uilding, Left/Right rear of building, Under deck
Address r—
µ.
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' State i
Telephone Number
B. Pumping Record ,
t
� Gallons
1. Gate of Pumping [fate 2. Quantity Pumped:
m......
3. Type of system: El Cesspool(s) ®Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p El Yep ( "to If yes, was it cleaned? ® Yes ❑ No,
5. Condition o Sy tent:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
�-
7. Lo cation wh� e contents were disposed:
. „
L .S Lowell Waste Water
Sign a qj Haule Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
N Vommonwea nn oT massacnus tts
City/Town of
System Pumping Record
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 4QBt front of ho , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City1rown State
Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown ' Statr
Zip C
Telephone Number
t
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Ls
Gallons
3. Type-of s stem:
system. ❑ Cesspool(s) eptic Tank F1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition f stes� ,,2k A, JJ '
`1L
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
Lowell Waste Water
Ze Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusett
City/Town ®f
a
System u ping Record
Form 4u,
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/gi6i t front of housi Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town St at, ,�,,�.�< � � ZAP Code vs
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date , Gallons
3. Type of system: ❑ Cesspool(s) [Teeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [-loo If yes, was it cleaned? ❑ Yes ❑ No
5. Condi ion of System:
-, V ::.
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company ,
7. Location where contents were disposed:
G L S. ) Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts ECEEI E Iw
Cit rFown ®f
System Pumping r
Form 4� "1fC.iWN a:��f PiORI a-9 A��Y�9i��p"VER
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 side of house, Right side of house, Left front of house hL ftq t f house,_)
r Y
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner:
f�
Name
--— - — ------ ---—---------- -----------
Address(if different from location)
City/Town Skater----
---- Zip Code
- -
� 9
Telephone Number
B. PumpingRecord
1. Date of Pumping Date 2. (quantity Pumped: Gallons
1 Type of system: ❑ Cesspool(s) ❑,,&eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [Q-N- _ 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 where contents were disposed-
L.S,D Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
�"N,C, R V K,:Lai
Commonwealth of Massachusetts 14-IL 13, M31
City/Town of
System Pumping Record
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
Important:
When filling out 1. System Location,
forms on the hcx-�%e
computer, use
only the tab key Address
to move your
cursor-do not City—M—ywn State Zip Code
use the return
key. 2. System Owner:
0
Name
err Address(if different from location)
City/Town Zip
State
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: Geuans
3. Type of system: ❑ Cesspool(s) EJ'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ef"'N'o' If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System um ed By:
J iame—� Vehicle License Number
Company
7. Location w e e contents were di posed:
1k
C-
Signature H Date
t5form4.doc•06103 System Pumping Record-Page 1 of I
TOWN OF do vv-,
SYSTEM
DATE' C °
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
,. (example: left front of house)
LATE OF PUMPING: ,_ (' O' QUANTITY PUMPED I )'0 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YE S
NATURE OF SERVICE: ROUTINE, EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL,TO OVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOL.ILDS CARRYOVE R OTHER(E LAIN)
SYSTEM PUMPED ELF BY: Ilateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFE D TO: G.L.S.D Lowell Waste