HomeMy WebLinkAboutSeptic Pumping Slip - 394 BOSTON STREET 9/2/2015 - f
Commonwealth of Massachusetts n
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City/Town of T ��, gym, „��
System Pumping Record HAY a 0 2014 �
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Form 4
k4� iaP °eau . " I {htEfv
DE-P has provided this form for us&by local Boards of Health Ot er corms may`"tip if ft; 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 t
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/ ' side of hq 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)
Citylrown State
Telephone Number 4
B. Pumping Record
1. Date of Pumping 2 Quantity ty Pumped:
Date 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. Condition of ste A
6. System Pumped By:
Neil Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 7GLjLS-P.G here contents were disposed:
\ L owell Waste Water
f
SignAtule cf Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I
RECEIVED
Commonwealth of Massachusetts
JU C"» 10 2013
City/Town of
1'OWN OF NORl"H ANDOVER
S stem Pumping Record
YS HEALTH DEPARTMENT—
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/Right rear of house, Left/(offi—Og�;j-�ous , Left
Right side of building, Left Right front of building, Left Right rear of building, Under deck
4 A
Address c- V
City/Town State Zip Code
2. System Owner:
.P- --e
Name'
Address(if different from location)
Cityrrown State Oda
-7)
Telephone Number
B. Pumping Record
>
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: F-1 Cesspool(s) 0-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ef No If yes, was it cleaned? ❑ Yes F-1 No
5. Condition of System:
V\,
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locat*"here contents were disposed:
Lowell Waste Water
Sign Atufe I Haule Date
t5form4.doc•06103
System Pumping Record•Page 1 of 1
i
Commonwealth of Massachu
City/Town of
System Pumping Record ° tIAN
Form 4 ugh � tii1� /� t
:,b µ rrµI y p 1 IVi��.:.� T ^ �a I @gym p�trp��p? q W( p�
O F 0�`v'kfN�iY"0 i^d, tt`MAk'��N��� � r
Y p 4p�M C dEi e DEP has provided this form for use by local Bo �i-�t er�s- ay 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/Right rear of house, Left ght s' e of oh useeft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address,
` ' "'
City(rown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityfrown State Cgde
Telep a Number
B. Pumping Record
1. Date of Pumping Date antity Pumped: Gallons
3. Type of system: El ;ZepficTank Cesspool(s) ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ®'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. Loc ' AHaule tents were disposed:
G.L Lowell Waste Water
c)
Sign #u a Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
M
Form 4
TOWN C0-NURTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other form ma 6.e- T
information must be substantially the same as that provided here. Before using Is orm, c ec wl 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 ear o house, right rear oftho se, left side front
of building, right rear f building nct rsidd6bX haus Left
City/Town State Zip Code
2. System Owner: ,❑
Name
Address(if different from location)
City/Town State Zs �� i�Code
'7 ��..
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) D'' p c Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D--No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S ystem-
6. Q �1
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
",O L.S.D,� L ell Wast W r
Signa ur of auler Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
i
�L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
Arm
DEP has provided this form for use by local Boards of Health. ther forms may be used, ut the
information must be substantially the same as that provided he e. Be arm, heck with your
local Board of Health to determine the form they use. The Syst m PingFdmust e submitted to
the local Board of Health or other approving authority. 'rOWN OF NONrH ANDOM
A. Facility Information
1. System Location: Left side of hous 6�1 ht
.§j-dg—of hg2§%Xeft front of house, Right front of house,
,3 —'
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
-A 'Re w'*o
Addresg
City/Town State Zip Code
2. em
S t Owner:
stem
Name
Address(if different from location)
City/Town State Zip Code
— 6--Xe- 3 ,- 12,751-1
Telephone Number
B. Pumping Record
1. Date of Pumping L/ 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) �--,5e'ptic Tank ❑ Tight Tank
F-1 Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ 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 contents were disposed:
Q.L/,i3.D Lowell Waste Water
qgrptute—of Haul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I
Commonwealth of Massachusetts � .""EIV-E ..
City/Town of 1
X
System Pumping Record APR 15 2009 �
Form 4 °
HE
DEP has provided this form for use by local Boards of Health. Other fo used;bufFie'W
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
Important:
When filling out 1. System Location: Left front, left rear, left side of house. Right front, right req , right side of hog .
forms on the
computer, use
only the tab key Address —
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:.
Name
Address(if different from location) j
City/Town State Zi d
Telephone Number
I
B. Pumping Record
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Type of system: El Cesspools) eptic Tank Tight Tank
i
jj Other(describe):
4. Effluent Tee Filter present? Yes Ej-f-o If yes,was it cleaned? Yes No
5. Condition of System: 0,,
nQ 6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
M.re u r D ate
t5form4.doc-06/03 System Pumping Record•Page 1 of 1