HomeMy WebLinkAboutSeptic Pumping Slip - 85 WINDKIST FARM ROAD 12/9/2015 Commonwealth of Massachusetts
= C ity/Town of . ..,01 3
System Pumping Record
:0v q 0l
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 Le` 'Y rig ide of hous4, 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 State
l
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 o 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. Locatio ere contents were disposed:
7M_L S. Lowell Waste Water
SignAtufe 4 Hauls Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
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TOWN OF
SYSTEM PUMPING RECO
DATE:
f A
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example:left front of Douse)
Of .�
DATE OF PUMPING: QUANTITY P ED : t)c-_) GALLONS
CESSPOOL: NO YES EPTIC T NO YiJs L
NATURE OF SERVICE: ROUTINE, v EMERGENCY
OBSERVA'T'IONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(E PL
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CON'TEN'TS TRANSFERRED TO: G.L.S.D Lowell Waste
Commonwealth Of Massachusetts . .�u
City/'Town of r
System Pumping Record 4�`i ' ' r EEC
Form 4
DEP has provided this form for use by local Boards of Health. Other foa, t/ `sed;'biatthre
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. Syst m Loc
forms on the
computer,use
only the tab key Address
to move your
cursor-do not City/Town , °`a .... ,' State Zip Code
use the return y �' „
G
key. 2. System Owner: "
Name
+ Address(if different from location)
City/T own State Code
"7
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Now If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f System: �� V `'
r/� jj (_0 �1 _-
lv, dl.AC,r l
6. System Pu peed By:
C � _
Name Vehicle License Number
Company
7. Location ere contener spored:
Signatur of au er Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
� .._
Commonwealth of Massachusetts RECEIVED..
City/Town of
j wq 15 no
System Pumping Record
d� Form 4 .q.�w� w����w w�d��N��w�� ��\cr is
u wn�
�._._HEALTH tv�im wW ARTPRNT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the I
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 rea<left side of house. ight front, right rear, right side of house.
forms on the
computer, use
only the tab ke y Address
to move your
cursor-do not City/Town Stake Zip Code
use the return
key.
2. System Owner:
)aAJ J-->�- V\
Name
Address(if different from location)
City/Town State ip Code
5--- I ,
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) eptic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? Yes No
5. Conditi n of S stem: ,� U/
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-wh re contents were disposed:
L.S.D Lowell Waste Water
igna ure of H Or Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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