HomeMy WebLinkAboutSeptic Pumping Slip - 210 GRANVILLE LANE 6/9/2016 Commonwealth of Massachusetts
i wn �� ° CE
YS
t pig r °�� i
f Form 4
�, J�.i.,Q,�
DEP has provided this ford far 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 forrim they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facilit3f. Information
1. System Location: Left/Right front of house(Le l Rig realr of hou eft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Lo
Citylrown State Zip Code
2. System Owner:
C)g '
Name
Address(if different from location)
Cityfrown ' State Zip Code ;
Telephone Number
B. r
i
Pumping ecor
.-
1. Date of Pumping pate r. 2 uantity Pumped: colic—nE--- --t
3. Type of system-. El Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye, 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
7. Locoo ere contents were disposed:
L S. Lowell Waste Water
Sign t e 9t Haule Date
t5form4.doc•06/03 System Pumping Record o Page 1 of 1
Commonwealth Of Massachusetts
City/Town of
System Pumping Record
Form 4
m. '
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 forth 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 boos L, g e g
y g ,"" ftti h ea of hatise Leff /right side of house, Left/
Right side of building, Left/Right front of b�fill�Irf ng, Left/Ri rare o building, Under deck
Address 1�
City/Town State Zip Code
2. System Owner: ex-
Name
Address(if different from location)
City/Town St at ip Code
T l
Telephone Number
B. Pumping ec r
1. Date of Pumping 2. Quantity Pumped:
Date - Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Na If yes,was it cleaned? ❑ Yes ❑ No
5. Conditio r6y`�-(P1kCt1A stem:
ry
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca ' r� h re contents were disposed:
G.L S Lowell Waste Water
Sign to a Haule Date
t5form4.doc•06103 System Pumping Record.Page 1 of 1
Commonwealth ®f Massachusetts .m.
w.
City/Town ®f RECEIVED
System u i Record
Form 4.
* i H�Q
O
DEP has p h Y ) h OWN ,
h
information must be substantially the same that provided here. Before this fo rm i—, &F66
with your
local Board of Health to determine the farm they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
wren cling out 1. System Location: Left fro I �.�.� ou .
rear, left side hau�s�Right front, right rear, right side of house.
farms on the
computer, use only the tab key Address C
to move your _.. Cd tCC .1. l
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town state e -Zip Code
Telephone Number
B. Pumping ec r
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: Cesspool(s) ep tl c Tank Tight Tank
Other(describe): -----—
4. Effluent Tee Filter present? ❑ Yes CO — If yes, was it cleaned? ❑ Yes [j No
5.
System:
on i Ian o�t -��� � •t�..-� . Vl�`�-� .: � t_� �
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
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
Con mon weak h of Massachusetts
c L)4"{
_ , Massac:ltuseits
Svstetu Pumpling
System Owner System Location
Date of Pumping: y Quantity Pumped: 1 f gallons
Cesspool: No fie° Yes Septic Tank: No IJ Yes
System Pumped by: Farcim 4 ftijej License #
Contents transferrred to : Greater Lawrence Sanitary Uistrtct
Date: _ _-- Inspector
Coil 1111oll weall 11 ormassachusetts
jlus5 tts
puttt in Record
System Owliel System Location
DAte of I'llfilpilig: Quailtily 11"Illped: k2!ell gallolls
Cesspool: N o N,es Septic Tmik: No Lj Yes
System Pumped by: vefredeft License #
Coillelits timisfiertred to : Greater Lawrence Sa"Itary District