HomeMy WebLinkAboutSeptic Pumping Slip - 386 SHARPNERS POND ROAD 7/11/2016 x a
Commonwealth of
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City/Town �� �Form 4 H ��� a ��
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 foram 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, Left/ ht side of hour` Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Un er ec-
Address
Cityrrown State Zip Code
2, System Owner:
Name
Address(if different from location)
City/Town State /J Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ®ate 2. Qu tity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition f ystem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7, Location where contents were disposed:
Lowell Waste Water
SignAtufe I Haule Date
t5form4.doc•06103 System Pumping Record-Page 1 of 1
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E Commonwealth of Massachusetts
City/Town of 1
System Pumping r L
o rR Form 4 I 4 DEPARTMENT
Nt d
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms to the ° ' D�1 f )C.`.._ M
computer,use _._� _ -
only the tab key Address
to move your
cursor-do not
City/Town Stale Zip Code
use the return
key. 2. System Owner:
V Q -
Name
6 Address(if different tram location)
— ---- -
City(Town $tats Zip Code
phone Number
B. Pumping Record
1. Date of Pumping -- 2. Quantity Pumped: ---------._..-_. -.
Date Gallons
3, Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? EdYes ❑ No If yes, was it cleaned? [ Yes ❑ No
5. Condition of System:
6. System Pumped By:
License Vehicle Name V Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4,doc•03/06 System Pumping Record•Page 1 of 1
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