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HomeMy WebLinkAboutSeptic Pumping Slip - 73 CARLTON LANE 8/9/2016 Commonwealth of Massachusetts City/Town of 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 Location: Left/Right front of house, Left 61 Lt rear of-hous6, Left/right side of house, Left Right side of building, Left Right front of building, Left/Right rear of building, Under deck Address 1 (,3 , Wel)A LLA- Oe--x4t)`- Cityfrown State Zip Code 2. System Owner: Name' Address(if different from location) Cityfrown State 71p C4 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Qu pntity Pumped: Canons 3. Type of system'., ❑ Cesspool(s) 0--Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [3-1q-o-'- If yes, was it cleaned? ❑ Yes ❑ No, 5. Condit" n f System: 4- V 6. System Pumped By: Neil Batesbn F5821 Name Vehicle U,rise Number Bateson Enterprises Inc- Company 0 2013 7. Lo ft contents were disposed: LZQ7 Lowell Waste Water w G- Sign Atufe qt-Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts u City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. O her a br tri m , t the information must be substantially the same as that provided here: ef6re 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, LefK/.Right rear of hos Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/ Right rear of building, Under deck Address Cityfrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip ode _ { Telephone Number B. Pumping Record ( 1. Date of Pumping pate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Q Septic Tank ❑ Tight Tank ❑ Other(describe): -- -- 4. Effluent Tee Filter present? ❑ Yes ©'No If yes, was it cleaned? ❑ Yes (] No 5. Condition of System: � ✓�,- �rc.,�-^--�'�... j 6. System Pumped By:. Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locaionn{here ontents were disposed: G.L S. 11 Lowell Waste Water i Sign toe Haule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 `w. v1" Commonwealth of Massachusettsw � . ` REC City/Town of 'i ME I System Pumping Record I)EC 15 200 0 Farm 4 TOWN OF NOR'n-i ANDOVER µ 1. DEP has provided this form for use by local Boards of Health. Other for information must be substantially the same as that provided here. Before using this form, check with your local Board of Health tQ 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 house, Left front of house, Right front of house, Left rear of ho se;F�'rght rear_otise. Left rear of building. Right rear of building. Address 3 s City/Town State Zip Code 2. System Owner: Name Address(If different from location) City/Town State r Z'CS�de Telephone Number-- B. Pumping Record 1. Date of Pumping - 2. Quantity Pumped: Date Gallons 3. Type of system: Cesspool(s) a .Septic Tank ❑ Tight Tank ❑ Other(describe): __ _...__.. ........___._._.... _.__—_ ....__.....__.__.__ 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sy� s � I 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. ZLocatio where contents were disposed: .D Lowell Waste Water-- _..._____ ------._.......--- Signature of Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF NORTH AN'D0VF.J,, 500C Yank: No NA r'URN OF s vEt,"e: ROU'r`IPk',..,., EMEAQh'NCY KMAVY M '1 IN r'lA . ROOM W LM: (11 i�Oc H���raDOV Fw Y . OrRg � XPLA,IN „ u �7-7/ 7K VUMMhN " . ��r