HomeMy WebLinkAboutSeptic Pumping Slip - 124 STONECLEAVE ROAD 5/13/2016 Commonwealth c u
u City/Town O
Pumping,System r
4
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 forrh they use,The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Inf®r i®
1. System Location: Left/Right front of house e
Right side of building, Left/Right front of buildiing, eft R Uf r, Left•/right side a house, Left/
house,
9 9 9 gg w f building, Under deck
Address
. ��..n �;: :� �,., ter.,,- �-••�.„��,.._��'
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityfrown ' � � State.
_/.y yZiCode
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons �—
3. Type'of.system: ❑ Cesspool(s) epic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p ❑ Yep ❑ No If yes, was it cleaned? F-1 Yes ❑ No,
5. Condition of st m:
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
Sign t e —HauleV Date
t5forrn4.doc•06/03 System Pumping Record• Page 9 of 1
Commonwealth Massachusetts �' ' r; l;%J E D
it own of
d Pumping
r`
Form 4
r,lPO MkF, ;
..... .
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. Infor tion
1. System Location: Left/Right front of hous .4%Right(eea 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)
CitylTown ' Stat
ZlpCode
Telephone Number
B. z �
1
Pumping Record
1. Date of Pumping Date 2. Quanfitf Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [I-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? �
p El [�""No If yes, was it cleaned? El Yes ❑ No
5. Condition of Sy tem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiwh,�ere contents were disposed:
G L S. Lowell Waste Water
w _
SignAtufe 9t Haule Date
t5form4.doc•06/03 System Pumping Record o Page 1 of 1
Commonwealth Of Massachusetts
n
City/Town of '-'d 14 N�
System un pin r d 01N0NO('�iH/ N'J(A4'-r
�i4 n� Pticrrf°efV �[r��rih �U
Form 4
M
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 house, 4e /L9 t!
µ s left/right side of house, Left
Right side building, Left g h font of i g, eft/Right /
rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State rc Zip„Qde
Telephone Number
B. Pumping Record
�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑,''!§eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ 0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System,
M ..
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
c.,
SignAtu'e I Haule Date
t5form4.doc•06103 System Pumping Record-Page 1 of 1
-,C\- Commonwealth of Massachusetts
0
City/Town of
System Pumping Record
Form 4 i j
F i
TOWN O NOMAITH ANUOM
DEP has provided this form for use by local Boards of Health. Other for a
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 Informati®n
1. S �tem_Loca.....On: Left side of house, Right side of house, Left front of house, Right front of house,
ar of hn -)Right ar of house. Left rear of building. Right rear of building.
civl�'.0
�
Address
City/Town State
System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone-Number
B. Pumping Record
1. Date of Pumping 2�eptic�Quantity Pumped:
Date ' Gallons
3. Type of system: El Cesspool(s) Tank ❑ Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? F-1 Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
_Cde
6. System Pumped By:
Neil Bateson _F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
LAS.D Lowell Waste Water
g to e of Haul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1