HomeMy WebLinkAboutSeptic Pumping Slip - 55 LOST POND LANE 7/7/2016 Commonwealth of Massachusetts
= City/Town Of
o System i
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 Right side of buitLL Left io f� .�.,.....M
'g se,�%deft/Right rear of house, Left/right side of house, Left/
g Right front of building, Left/Right rear of building, Under deck
Address
CitylTown State H � V odd
2. System Owner.
Name
"("OWN OF ()r I H AND w E R
Address(if different from location) - 1"'AFi i EN'r
Cityrrown State .. _ Zip Code
Telephone Number
B. Pumping Record
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 ff No If yes,was it cleaned? ® Yes ❑ No
5. Conditi n System: w.
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiaxt wb pre contents were disposed:
Lowell Waste Water
17
Sign toe I Haule Date
t5form4.docr 06103 System Pumping Record^Page 1 of 1
Commonwealth of asp chu tts
--
City/Town of
System in
- Form
'{M
( P
DEP has provided this form for use by loc Boards'�➢of Heaiik other rms may be used, but the
information must be substantially the sam as that provided here. Be re using this form, check with your
r2 °� ping Record must be submitted to
the alocal aBoard of Health or other atheovin t '� � .�.
PP h`Iw u�r .��� �
A. Facility Information
1. System Location: Left side of house, Right side of house, ft f nt o ou e- ight front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear o building.
Address ----- �.
Cityrrown State Zip Code
2. System Owner:
0.-
--------—----------
Name --
-------------- — - --- ------- ----- —
Address(if different from location)
---------------—
----------
City/Town Skate �~-~4�� -'-----� ..---f �ode
Telephone Number
B. Pumping ecor
1. Date of Pumping - - -Date Gallons 2. Quantity Pumped: --- --------------
3. T yp e of system: ❑ Cesspool(s) ❑ e.p_.ti
c Tank El Tight Tank
❑ Other(describe): - — ---- -
4. Effluent Tee Filter present? ❑ Yes ❑ o 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. Location where contents were disposed:
G.L.S,. die Waste Water
Sig tur b auler Date
t5form4.doc•06/03 System Pumping Record<Page 1 of 1
V l,./V•.J/J.JJ� VV.•JV JV�JJ f..lV V11 JIG'f�/MIf',1/NIVL�l1V G.i"<. I-HIaG Vr" '.....
tTIS SEPTIC TANK S
I b mcaln -f 47 RMLRoAD S
A14 /'Ih A BWFORD, fh 01835
Li c- 978®372-7471
rn � (1 L�
tTMOF r !
MXMiLy REPORT FOR XM OF
DATE ADDRESS
Ns
d '' , 1,
v/
hn
106o
UG-C1 � U