HomeMy WebLinkAboutSeptic Pumping Slip - 371 STEVENS STREET 5/3/2016 Commonwealth
x City/Town of
Pumping YS
r P,I
Form 4
DEP has provided this form for use�by local Boards of Health. Other forms y`b , bit 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 o Left
front Left t re ar oiauset Left/right side of house, Left/
Right side of building, Left Rig ht frant of buildin g,L Rl gf rear 6f
building, Under deck
Address ) "
r
l
CitylTown State Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown ' State Zip Code
3 1 G
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped
Gallons
3. Type of system. ❑ Cesspool(s) S e p ri s Tank Ej,,Tight Tank `
❑ Other(describe): _a ..
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio of stem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiota There contents were disposed:
GAL S. Lowell Waste Water
Sign t WHa ( Date
t5fomY4.doc•06/03 System Pumping Record•Page 1 of 1
i
w
. w
Commonwealth of Massachusetts
u City/Town of f
System i
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/Right front of house, Left` ht rear of hoy b, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left g`h "rear of building, Under deck
Address �"7
tC
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State
Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
. ....,w.
3. Type of system: ❑ Cesspool(s) ❑peptic 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
L H contents were disposed:
7. Location where
f _ ... Lowell Waste Water
4 naA
c._.,. �... ..
Sign toe I Haule Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
W City/Town of 'Ik a, E
System ors Record
Form 4
GA @�� W,ry;ry��„ app �ygp �yW
u WW V"'�'w�PM� N[','Zhd'Ew!�"�R
DEP has provided this form for use by local Boards of Health. Other for
information must be substantially the same as that provided here. Befor a bfiebk 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 fro house, right front of house, left side of house, right side of house, Left
rear of house Ight rear of ou ,e0left side of building, right rear of building, under deck.
AAI� v<A-.0JJ4-'-
CityTrown State Zip Code
2. System Owner:
Name -
Address(if different from location)
City/Town State,/) ��'4 r �9Z�p Code
Telephone Number
B. Pumping ecor
1, Date of Pumping D ate 2. Quantity Pumped: G -
Gallons
3. Type of system: ❑ Cesspool(s) 0-Septic Tank ❑ Tight Tank
❑ Other(describe): -- /- - --
4. Effluent Tee Filter present? El Yes ®moo If yes, was it cleaned? ❑ Yes ❑ No
5. Gonditio of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7, Loca. ere contents were disposed:
.L.S.D. Wv4ll Waste WaW
Signature o H I Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1