HomeMy WebLinkAboutSeptic Pumping Slip - 35 BROOKVIEW DRIVE 6/5/2012R EEC V k"'
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
juN U Li 1?
TOVVN OF NORTH ANVVOVER
HEEAL.TH LiE.':.PArcrIMENT
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 ight.r.ear_ofimusel Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
(
V, (2-t_,J
City/Town
2. System Owner:
State
Zip Code
Name
Address (if different from location)
City/Town
Sta
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
3. Type of system: 0 Cesspool(s) Erge-iptic Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes El< If yes, was it cleaned? 0 Yes 0 No
5. Condition of System:
04-
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
.L S
Lowell Waste Water
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
IRo:CEIV
APR 2 3 7009
rovvN OF NOR PH ANDOVER
DEP has provided this form for use by local Boards of Health. Oth -to
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 front, left rear, left side of house. Right fro
Address
Carp-10<A)
City/Town
2. System Owner:
State
, right sid
Zip Code
Name
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system:
Other (describe):
‘-f
. 2Quantity Pumped:
Date Gallons
Cesspool(s) 0-851511-81-ank 0 Tight Tank
4. Effluent Tee Filter present? LJ Yes
5. Condition of System:
<\ (A,
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. LocationLocatiow1ere contents were disposed:
Lowell Waste Wate
If yes, was it cleaned? 0 Yes 0 No
F 5821
Vehicle License Number
Date
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
AUG 3 1 7.(10
OF iggIRTH A4gOy4Ft
DEP has provided this form for use by local Boards of Health. Other
information must be substantially the same as that provided here. Be& e'Lrilig Itilb fulfil, 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: Leftside-of-houseight side of house, Left front of house, Right front of house,
Left rear of hous ight rear of house.„.I2eft rear of building. Right rear of building.
Address
difYirewn
2. System Owner:
Name
Address (if different from location)
CitylTown
State
Zip Code
Stat
Zip Code
Telephone Number
B. Pumping Record
(
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: Cesspool(s) Septic Tank El Tight Tank
11 Other (describe):
4. Effluent Tee Filter present? LJ Yes E610---- If yes, was it cleaned? 111 Yes E] No
(
5. Cond. .on of System:
6. System Pumped By: .
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
aste W er
Signature of
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the -return
key.
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The S
i[ JUN 2 N J OG'
ust
be submitted to the local Board of Health or other approving authoriy.
A. Facility Information
1. System Location:
City/Town
2. System Owner:
Name
• Address (if different from location)
City/Town
Ct
Telephone NUmber
State
Zip Code
B. Pumping Record
1. Date of Pumping
Date
--(11A5
2. Quantity Pumped:
3. Type of system: LJ Cesspool(s) BePiroTank
D Other (describe):
4. Effluent Tee Filter present? LI Yes a-N-6 If yes, was it cleaned? E] Yes 11] No
Gallons
El Tight Tank
5. Condition of System'
QJ2 :4
6.
System Purrtped,BkJi
Name
Company
Locati n where content we
Signur6f IiuIer
hftp://vvww.mass.govidep/water approve / 5 orms.htm#inspect
"posed:
Vehicle License Number
Date
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1