HomeMy WebLinkAboutSeptic Pumping Slip - 120 CARLTON LANE 8/9/2016 Commonwealth of Massachusetts
w w City/Town of
System Pumping Record
Form 4
DEP has provided this form for use,by local Boards of Health. Other forms may be bsed, 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 RBI ht�front of hous Left I Right rear of house, Left/right side of house, Left/
Right side of building, Left I Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. Syste Owner:
Name' _
Address(if different from location)
City/Town ' State
Zip Coda..,
Telephone Number
B. Pumping Record
1. Date of Pumping a
Date Quantity Pumped: 0
Gallons
3. Type of system: ❑ Cesspool(s) 1:9/septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 112/No If yes, was it cleaned? Ej Yes 0 No
5. Conditi n of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign t e Haute mate
t5form4.doc•06/03 system Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts RECEIVE
City/Town of
System Pumping Record
ro
v ()I" NOR J
TO
Form 4 WN
HEALI'H,i,'.%,FwARTME114T
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 forrn 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 �ih��-tt-f��166ni of hou Left/Right rear of house, Left/right side of house, Left
Ic
Right side of building, Left Ig t front of building, Left Right rear of building, Under deck
Address
Q0 r- 2
City/Town State Zip Code
2. System Owner:
k VO
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) 3/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 3/No 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",ntents were disposed,:
'C "'S
Lowell Waste Water
owell Waste Water
I
toe au
ISIgne H ule Date
t5form4.doc-06103 System Pumping Record-Page 1 of 1
a.
P, F
Commonwealth of Massachusetts
City/Town oft
System Pumping Record
Farm 4 ,I
�me
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority. .
------.---- -- - _
A. Facility Information
Important:
When filling out 1. System Lopation:
forms on the
computer,use
only the tab key Address
to move your r ( ._� �(J
cursor-do not --------- 1
use thw return City/Town State Zip Code
key. 2. System Owner: e
Name
-- - ._...._..
n Address(it different from location) _.._— ------
CityfTown State -
Telephone Number
B. Pumping Record
1. Date.of Pumping Pate"... - 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool($) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? .0 Yes cl�o If yes, was it cleaned? ❑ Yes F] No
5. Condition of System:
6 Syste P mpe d Ry"
Name _ ��'"`°""°..+ Vehicle acense Number
Company
7.
w l „1t1(P
sed:
Locatio � here conten re di
,
0
Sign ure a er Date
hftp:I/www.mass.govldeD/w er approval8/t5forms.htm#inspect
t5form4.doc-06103 System Pumping Record•Page 1 of i