HomeMy WebLinkAboutSeptic Pumping Slip - 353 BOXFORD STREET 5/16/2016 Commonwealth
System Pumping Record
Form 4
I
I fI ( (I
X11 �
UEP 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 hare. 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, LeftRi ht rear of hoes , Left/right side of house, Left/
Right side of building, Left/Right front of building, Le Ig :re uilding, Under deck
Address
mm
City/Town Mate Zip Cade -
2. System Owner:
Dn 11A"Y
Name
Address(if different from location)
City/Town ' Sta4��C. � p Cade '
d
Telephone Number
B. Pumping Record
9 t
�•� ���._.( � ��� �.,�»
1. Date of Pumping 2. Quantity umpe
Pumped:
Gallons
3. Type of system: Cesspool(s) eptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was It cleaned? El Yes 0 No
5. Condition of System:
f m.,
6. System Pumped By:
Nell Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiog.where contents were disposed:
#S. Lowell Waste Water Sign e Gate '
t5form4.doc®06/03 System Pumping Record«Page 1 of
Commonwealth Of Massachusetts
2 City/Town Of
System u pin r °� :
Farm 4 � f NOR ANDOVER
DEP has provided this form use b local Boards of Health. Other forms may be
P Y Y 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 84 h
g �fJ� %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)
CitylTawn State %Zi �Code
� CCU c�
Telephone Number
B. Pumping Record �. _. ,.
1. Date of Pumping ®ate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Sep Ict Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No
5. Condition o System:0 W-1—)
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
,rte.,_✓ C ._... �..n� ` � ,,
Sign to a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
m
Commonwealth of Massachusetts
RE 'ED
- �
:HAND�vr.R�
ity/hoWn cf
System Pumping FHEALIV Form T
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 tQ 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 g.-bou µ„Right side of house, Left front of house, Right front of house,
Left rear of housght rear of haul Left rear of building. Right rear of building.
Address _
M
City/Town State Zip Code
2. System Owner:
Name
- - -- ---
--- ------ ------
Address(if different from location)
Cityfrown State y C" ip Code
Telephone Number
B. Pumping ecord
1. Date of Pumping 2. Quantity Pumped: ---
Date Gallons
3. Type of system: ❑ Cesspool(s) El"Septic Tank ❑ Tight Tank
❑ Other(describe): --- -
4. Effluent Tee Filter present? ❑ Yes Na If yes, was it cleaned? ❑ Yes ❑ No
5. Condit' f System:
f.. _ < _.
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locate n uJfter contents were disposed:
G.L.S. Lawel Ate Walear�._.
Sign/re a er Date
t5form4.doc•06/03 System Pumping Record^Page 1 of 1
t
Commonwealth of Massachusetts
City/Town of
a o
System Pumping Record
.o
Form 4
ry 4
g0
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: C °`
When filling out 1. System Location: Left front, left rear, left side of house. Right front, fight rear ight sid of ouse
forms on the
computer, use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
Vfia — -- --
Name
Address(if different from location)
City/Town Stat i Code
,
y V� w'_ C p
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) 0'°" eptic Tank Q Tight Tank
Other(describe): --
4. Effluent Tee Filter present? ( Yes Q-N'0 J If yes, was it cleaned? ❑ Yes Q No
5. Condition of System: j
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc _
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water_
A re of H u r Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
r
Commonwealth of Massachusetts
a= it /Town Of I ' f.i�, �, ,,
1 .. � � .11(If
System rain Record
.` Fora 4
DEP has provided this form for use by local Boards of Health. 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:
farms on the
computer, use C
to move our — — w
—— -
only e a key Address
C.
Bursar-do not
use the returnity/T°wn State — Zip Code —
.key.
2. System Owner:
Name ---- -- — — — --- —
Address(if fferenk from location) --— --— -- -----— --
Cikyrrown — µ
Skate �`---
��, Z��Code
Telephone Number -- ----
Pumping Red6rd
1. Date,of Pumping oate — 2. Quantity Pumped: -- - —
Gallons
3. Type of system: ❑ Cesspool(s) LI epiic Tank ❑ Tight Tank
❑ Other(describe): - ---- --- --- --- - — --- ---=
4. Effluent Tee.Filter present? ❑ Yes .a No If yes, was it cleaned? ❑ Yes ❑ No
5. Condit* f System u
6. System Pup
Name
V -- =— - -- ------
r,
ehicle License Number
µ.
w
Company --- —
7. Location ttre contents wr diosed:
W
-
Signa re 0"„ aul Date — — -- -- — -
http://www.mass.govi/dep/wa er/ap rovals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record•Page 1 of 1