HomeMy WebLinkAboutMiscellaneous - 230 GRAY STREET 4/30/2018 (3) Q
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Commonwealth of Massachusetts
Wal City/Town of RECEIVEDSystem Pumping Record
y� Form 4 JUL ` 2 2012
DEP has provided this form for use by local Graf rms may be used, but the
information must be substantially the same[ 113ef re using this form, check with your
local Board of Health to determine the form they use.The System umping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Leff/-Right-front-of-housAedlnLeft
Rig rear of hous , Left/right side of house, LeftRight side of-b a>ng, Left/Right front of bu /Right rear of building, Under deck
Addresso" l�
Cityrrown State Zip Code
2. System Owner. T
n, v
V\aN
Is
ame
Address(if different from location)
City/Town State4=-:�S=r �, `l�_Zip ode`�v
Telephone Number `-t ,
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 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. Lo re contents were disposed:
G. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
�LN Commonwealth of Massachusetts
City/Town of JUN 3 J 2010
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
' M
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 tq determine the form they use. The System Pumping Record must be submitted to
the local Board of Healthor 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,
e rear of hous , Right rear of house. Left rear of building. Right rear of building.
Address y .'
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stat Zip .de
c P
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 No If yes, was it cleaned?, ❑ Yes ❑ No
5. Con iti n of Systeml,&'tj"P�L
0- --477-�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ehecontents were disposed:
G.L. well Waste Water
Signfitur6 o Hauler V Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1