HomeMy WebLinkAboutSeptic Pumping Slip - 196 SUMMER STREET 7/20/2016 Commonwealth
1
City/Town
System Pumping Record
Fora 4
DEP has provided this form for us&by local Boards f 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' f t igh rout of hou , Left/Right rear of house, Left/right side of house, Left/
Right side of bui trig, Left/ I h-t'frodt o building, Left/Right rear of building, Under deck
Address .
1
City/Town Mate dip Code
2. System Owner:
Name
Address(if different from location)
City/Town f
' Mate °" Code
µ, r"
Telephone Number
B. Pumpin r
1. Date of Pumping 2
�at�� Pumped:
..
. Quantity Pd:
3. Type of system: El Cesspool(s) Septic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? M e ® No If yes, was it cleaned?
S. n of sy tem:
. ,
6. system Pumped By: ;� �, ..
.„
Nell BateSbn F5321
Name Vehicle License Number
Sateson Enterprises Inc
Company
7. Locationwh contents were disposed:
ISignt S. Lowell Waste Water
1 "j Haule Cate
t5form4.doc$06/03 system Pumping Record-Page I of 1
Commonwealth of Massachusetts
City/Town of
4° System Pumping Record
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. System Locatio . eft ig ront'of hous eft/Right rear of house, Left/right side of house, Left/
Right side of bui Ing, Left/ Ig ron of building, Left/Right rear of building, Under deck
Address l
Cityrrown c State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
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 0 No If yes, was it cleaned? Yes ❑ No,
5. Condition of System: 1 1
J�J Of .
6. System Pumped By:
Neil Bateson F5821
i
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7.
;here contents were disposed:
O L.S Lowell Waste Water
�-M. C z- 1�3
e H
Sign e
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
r"W""El_61-I V Eff"m
City/Town of C
System Pumping Record
Form 4 OC13, el"116 201?
T�W
A,
TOWN C)F NORTH ANDOVE,R
DEP has provided this form for use by local Boards of Health. Other f
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 side of house, Right side of hous Qi?, Right front of house,
Left rear of house, Right rear of house. eft rea f ildin Ri ht rear ot building,.---
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zll�Code
Tel phone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) [D-ge—ptic Tank F-1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑El,-Y No If yes, was it cleaned? Q-1-e-s ❑ No
5. Condit* n afu,�,ystem,
Q,
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location,.wktre contents were disposed:
Lowell Waste Water
qgqAtoe of Haul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
W City/Town of
System pin Record
M
Form 4
DEP has provided this form for use by local Boards of Health. Other forms ayKeif `` �
f t
information must be substantially the same as that provided here. Before us 16 f rm, 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
-
I Right ht s deoof building, Le Ig i
fro ht f ontoou Left/Right rear of house, Left/right side of house, Left/
g g,(� g� f building, Left/ Right rear of building, Under deck
Address " 1
.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ® eptic Tank ❑ Tight Tank
®either(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio n of System- r
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatiotLuhere contents were disposed:
Lowell Waste Water
Sign toe Ha le Date
t5form4.doc-06103 System Pumping Record-Page 1 of 1