HomeMy WebLinkAboutMiscellaneous - 962 TURNPIKE STREET 4/30/2018Commonwealth 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, Left11 t rear of houses, Left / right side of house, Left /
Right side of building, Left ! Right front of building, Left / Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address (if different from location)
City/Town "• a' " "" `r State
i
�ip,Code
20
}31; Telephone Number
T,1D,W,R 0.F NQRTH`AND0VEW,
B. Pumping Recr::e;.,..
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 [x'140 If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition f System: i� I ) k � W
411--
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location re contents were disposed:
Lowell Waste Water
wle j Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
W°
System Pumping Record R�C��VE®
Y p 9
Form 4 Plnjv '1 �, 2010
°a r
DEP has provided this form for use by local Boards of Health. Ot end"TMjpjthe
information must be substantially the same as that provided here. BT Y ck with your
local Board of Health to determine the form they use. The System mping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner: T 7A
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
CC- 5 =rte
— 2. Quantity Pumped:
a,geptic Tank
Date
Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Leo
5. Condition f System:
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Locatio ere contents were disposed:
S.D. Aowdll Waste hateF,
Stat,
ip Code
��
Telephone Number
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1