HomeMy WebLinkAboutSeptic Pumping Slip - 1132 SALEM STREET 12/9/2015 f
Commonwealth of Massachusetts
City/Town of
System Pumping cord
Form 4 v), � 1
DEP has provided this form for use=by local Bo rdsw��, 1 Itfr,10,h��#orr� may be'used, but the
information must be substantially the same as t at`�ir ad !' re °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/ . h�rear of hoys�, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/ Ig ar of building, Under deck
Address
t (2)_�_ <�C,L
Cityrrown State Zip Code
2. System Owner:
A<(0 e,�
Name
Address(if different from location)
Cityrrown ' State Zip Code
, ? ( JCS _
Telephone Number
B. Pumping Record
1. Date of Pumping Date ' 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. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatiCh—Whore contents were disposed:
GLL S. Lowell Waste Water
signitufe qt Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts � � „�
W
City/Town of
Y
a
System Pumping Record 0
Form 4
j ru ANDOVER VER
DEP has provided this form for use by local Boards of Health. Othe for � e'Trsed "but"the
information must be substantially the same as that provided here. Before using this form, check with your 1
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 side of hou Right side of hous ,J eft front of house, Right front of house,
Left rear of house, Right rear of ha`tts .
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Q--Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
ac
cA -.
6. System Pumped By:
Neil Bateson
Name Vehicle License Number F5821
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.L. Lowell Waste Water
Sin ur of Haul Et/ Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1