HomeMy WebLinkAboutSeptic Pumping Slip - 1500 FOREST STREET EXT 6/23/2016 Commonwealth of Massachusefts
C4/Town of
M ,
System Pumping Record
f
Form 4 ov '1 01
r
CEP has provided this form for use by local hoards of Health. �3#het foLWYYP�,, - e
information must be substantially the same as that provided here. efr� ;ry k 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/Right rear of house 6f /rig ide`of house,j ft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address .,
Gityfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' Mate Z de
Telephone Number
B. Pumping w _ °( C
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
. Type of system: esspool(s) ep Tank Ej Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Ye B-60 if yes, was it cleaned? Yes No
5. Condition Pstem.
6. System Pumped By:
Neil Rateson F6821
Name Vehicle License Number
Bateson Enterprises Inc
company ,
7. Location.. her contents were disposed:
L 5. Lowell Waste Water
f
sign t e �Ihule date
t5forrM.doc•06/03 System Pumping Record m Page 1 of 1
Commonwealth of Massachusetts
City/Town � um,
M of
a System Pumping r t !
Form 4
M I
I' f; s'!' rj`,4Y, 1
DEP has provided this form for use by local Boards of Health r a li ai, 'Out the
information must be substantially the same as that provided hc�e:� efor&6sirtg'Ah rte;°°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/Right rear of hour Let?right Ide of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under decd"
Address .� . . „ r_.w..-� trv_ ,.....�r'�..:. �.,;�,':��,z�'t"��..�'C�.�_..-... �'" `*✓4....` '� -µ•tom-`
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State. -_j Zip p8oe
Telephone Number
B. Pumping Record cw W.
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ®-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ "llo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S ste
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 to a I Haule Date
t5form4.doc^06/03 System Pumping Record^Page 1 of 1
Commonwealth Of Massachusetts
System City/Town of E JD '
a r 11('01k '01
Form TOWN N N
�
DEP has provided this form for use by local Boards of Health. Other f t_Ti � PArT ENT
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health t4 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. Ze:ft yste ion: Left side of house, Right side of house, Left front of house, Right front of house,
d g — teft rear f budln Right rear of building.
rear of house Right rear of
house. � a�RI W �
�'�
Address �d ❑W ❑�° -- -- -- ,
--
City/Town State Zip Code
2, System Owner:
— ------- --
Name ❑ -- 0 ------
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record - -
1. Date of Pumping 2. Quantity
Pumped: Gallons 3. Type of system: Cess p ool(s) CSp tic
Tank El Tight Tank
❑ Other(describe): -— -------
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f ystem:
/��OJ Ceue
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company ------ ---- -
7. Loco � re contents were disposed:
er
Signature er
S. Lowell to
Signature er Date
t5form4.doc-06/03 System Pumping Record.Page 1 of 1
Commonwealth SS c u is
City/Town
System Pumping
ug Form
DEP has provided this faun 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 farm, check with your
local Board of Health to determine the farm they use. The System Pumpin R
r be submitted to
y must + .
the local Board of Health or ether approving autharlt . A ;
® Facility Information MAY 0 6 200
Important: r
When on t out System �N
filling 1. Location: i I i/0 r CM/
forms on the C ; F I f l f�
computer, use ... ._. °
only the tab key ddress
to move cursor-danoty qty � � .� � � �� ' ."
use he return p �
Zip Cade
key. 2. System Owner:
Name
n Address(if different from location)
City/Town St�e� � � w..,_..�W�r �° Z* Code
Telephone Number l
B. Pumping Record
1. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) El'-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0J"'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of�System:
.�.�2^a�,
6. System P
rp
:
Name �, Vehicle License Number
Company
7. Location 0 ere contents
wer . spased:
-Signature/of Ifauldw Date
t5form4.doca 06/03 System Pumping Record 4 Page 1 of 1