HomeMy WebLinkAboutSeptic Pumping Slip - 80 LOST POND LANE 7/7/2016 Commonwealth
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City/Town c °��
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Form 4
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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. In r ti
1. System Location: Left/Right front of house, Left i ht rear of house,' eft/right side of house, Left/
Right side of building, Left/Right front of building, Left ig ar dMilding, Under deck
Address -
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town sta � .! YZip Cade '
I C{
Telephone Number
B. i
Pumping record
15
1. Date of Pumping ®ate 2• Qu6ntifv Pumped: Gallons —`
3. Type of system: El Cesspool(s) Septic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? ® Yes ® No,
' 5. Condition f ,rstem:
6; System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loca' n- here contents were disposed:
GLLSQ Lowell Waste Water
_ —
_Signku I Fe qt Haule Date r
0orm4.doo-06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
City/Town of
a
System Pumping Record
Form 4
FIJEAM4 ttAl F NORT.H .A ANDOVER P17 O
A
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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 front of house, LeV]RI'"nt rear of house,-.Ieft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
.. cz -\'
Name
Address(if different from location)
City/Town State ,Zip Code
Telephone Number
B. Pumping Record
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 a -No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
❑❑ �. ugj- .
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 7Loc io rf w sere contents were disposed:
L S. Lowell Waste Water
._._..
Sign toe 4 Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
North Andover, Massachusetts
System Pumping Record
System Owner & address:
Erica Fagan
80 Lost Pond Lane
North Andover, MA
Location of system: Rear
Date of Pumping: November 17, 2008
Type of system: Septic
Gallons Pumped: 1500 Gallons
System pumped by:
Service Pumping & Drain Co., Inc.
5 Hallberg Park
North Reading, MA
License #: BHP 2007 0728, 0725, 0727,0722, 0724, 0726
Contents transferred to: Greater Lawrence Sanitary District
Date: November 17, 2008 Pumping Technician: DM
This is PROPRIETARY and CONFIDENTIAL information that may be used only
by the Board of Health for regulatory purposes
FORM 4-SYSTEM PUMPING RE. ,
SEPTIC & DRAIN SERVICE
107 FOREST STREET;MIDDLETON,MA 01949
(978) 774-2772
OMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
SYSTEM OWNER: - r� - SYSTEM LOCATION: g &l
Ft
UtG O ll/
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C'o uG�""
DATE OF PUMPING: 3 --,?3 QUANTITY PUMPED: / � GALLONS
CESSPOOL: NO F—] YES SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: G"r l S D
DATE: -g ✓ 5' 7 INSPECTOR:
o-