HomeMy WebLinkAboutSeptic Pumping Slip - 195 OLYMPIC LANE 6/9/2016 Commonwealth u
u City/Town of City/Tow
d System. ; 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- Right ra t of hous` , Left/Right rear of house, Left/right side of house, Left/
Right side of boilLeft/Right front of building, Left/Right rear of building, Under deck
Address
,, (-1/ te
Cityfrown �,j State Zip Code
2. System Owner:
Name f
Address(if different from location)
City/Town ' State �Zi NC ode C
Telephone Number ``•;
a t
B. Pumping ecor
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system- ❑ Cesspool(s) ❑-S e p tic Tank
Tight Tank
❑ Other(describe);
4. Effluent Tee Filter present? ® Yes ❑` If yes, was it cleaned? ❑ Yes ® No;
5. Conditio of stem: /
6; System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locationrwher contents were disposed:
.�S. Lowell Waste Water
. - _. ._.
Sign t e I-HauleV pate
t5form4.doc•06103 System Pumping Record•Page 1 of 1
TOWN OF NORTH 4
SYSTEM PUMPING RECORI)
DATE: hG/o/
SYSTEM OWNER& ADD RE SS SYSTEM LOCATION
(example: left front of house)
C
1 R j- ) "C
DATE OF PUMPING: A A QUANTITY PUMPED f GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE -BAFFLES IN PLAICE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: _ .� G ,) C t �° n c
COMMENTS:
CON'S'ENTS TRANSFERRED TO: e C j Q i � q t e_ (A.xjec
Commonwealth of Massachusetts
M City/Town of T T
y 'trrn Pumping Record
Form 4 , 51"
4
DEP has provided this form for use by local Boa di ' Health Thi Pumping' ��tb Pu to Record must
be submitted to the local hoard of Health or oth r•ap"provtng autharlt W „�
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use k „
only the tab key Address
to move our City/Town t ._ tl
'"
cursor-do not
.
use the return State Zip Code
key.
2. System Owner;
Name — — —
Address(if different from location)
City/Town State Zip Code
1 Telephone Number
B. Pumping Record
1. Date of Pumping 6c,�
Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ 'Other(describe);
4. Effluent Tee Filter present? Q`Yes ❑ No If yes, was it cleaned? "*Yes ❑ No
5. Condition of System:.
6. System mped By:
Nam ,( i,„ Vehicle License Number
@ umber
Company —
7. Location where contents were disposed:
Signature of Hauler Date
hftp,//www.mass,gov/dep/water/approvaIs/t5forms,htm#inspect
t5form4.docr 06/03 System Pumping Record•Page 1 of 1