HomeMy WebLinkAboutSeptic Pumping Slip - 45 SHANNON LANE 7/11/2016 Commonwealth Of Massachusetts
City/Town own of �k��k �` f�� f
System s in Record
i��,r n Mvi:ni�
®r
GEP 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 Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left T`R@11t1f b uilding, Left/Right rear of building, Under deck
Address
Cdy/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown State., Zip Code ;
Telephone Number w
B. Pumping ecor
1. Gate of Pumping Date 2. Quantity Pumped:
Lallans
3. Type of system: ❑ Cesspool(s) eptic Tank Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of stem:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location where contents were disposed:
C L S. Lowell Waste Water
�...
SjgnAtuTe ct Haule date
t5form4.doc•06103 System Pumping Record*Page 1 of 1
L\ Commonwealth Of MaSSaGhusetts �w �....
City/Town Of
System u i r jI ,
Form 4
a
DEP has provided this form for use by local Boards of Health. Other fo k "secf 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
farms on the ....,._ht front__�.�,..............
Important:
When filling out 1. System Location: Left front of ha se, Right front of house,-Leh rear of house, Right rear of house
,. ....
computer, use —
-------only the tab key Address
to move your -- ., C ,Cr ,r�, ,.a .....
cursor-do not ----- --------
--- ------- ----- -------
use the return City/Town State Zip Code
key. 2 System Owner:
VQ _A ,..., .
Name
rrn®n Address(if different from location)
Cit fawn � e
Y Stat � �
�._ — --
Telephone Number
B. Pumping Record
a Gallons
1. Date of Pumping Date--�-"- 4�--- ----- t2. Quantit y Pumped:
3. Type of system: ❑ Cesspool(s) E3"9eptic Tank ❑ Tight Tank
❑ Other(describe): ----- --
4. Effluent Tee Filter present? ❑ Yes []-'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condit of System:
6. System Pumped By:
Neil Bateson
Name Vehicle License Number F5821
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
" L.S�D ...w L e aste Water
.,. s
Signat re f H ter Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
LDATE: ... ...
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
4
,. .(� V
LATE OF PUMPING: ..
GALLONS
CESSPOOL: NO � -_ YES SE IC T : NO YES
NATURE OF SERVICE: ROUTINE, �� EMERGENCY --_--
OBSERVATIONS:
GOOD CONDITION +ULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIE L D RUNBACK --
EXCESSIVE SOLIIDS — FLOODED
SOLIDS CARRYOVER OTME R(E LAIN)
SYSTEM PUMPED BY. Bateson Enterprises, Inc.
COMMENTS: _
CONTENTS TRANSFE RRE ID TO:
Commonwealth of Massachuselts
IV1ass cl usetis
Sys @ern Otvner System t,oca @fort
Date of Pumping: t c') ' k: � �� �� � Quafrlily Pumped; ������ gallons
Cesspool: No H"" Ves I_ Septic Tank: No IJ Yes Iw1
System Pumped by: getrejea Sre&V.,?ided License
Contenis lransferrred to ; Greater
Date; ------ ------—— - — l rrspteclor.
L 5
Commonwealth of Alassachusetts
Massachusetts 00000
?. wn rig r
-LV��•ste�i� rr ner �_.�'..�.. ..`�. SyStciri Lacaitor� •___�.._ .�
Date of Pumping � �' `� '� Quar7titV Pumped: t
I
Cesspool: No lei Srnrir Taal hen ,_ Yes
System Pumped by- __— License #:
Contents transferred to:
Date _- Inspector
y