HomeMy WebLinkAboutSeptic Pumping Slip - 53 WHITE BIRCH LANE 12/15/2015 i
Commonwealth of Massachusetts �. � �.
i City/Town of
System Pumping Record 1' " � `;° �4°
s
Form 4
Y
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/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address s
dry
Cityrrown State Zip Code
2. System Owner:
Name
i
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —� I 2. Quantity 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 System:
Qo(0,14
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign toe CfHUUJ0FU Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
H City/Town of
System Pumping Record
Form 4 T(J VWJ AWOVE
i CEA ui l Y i,k'f i l l iN l
DEP has provided this form for use by local Boards of Health. Other forms may used, but the J
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 i tit front of house,deft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ tl ht ron of building, Left/Right ear o uilding Under deck
Address
Cityrrown State Zip Code
2. System Owner:
11, +-VIA fry.
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date �' Quantity Pumped: pan
3. Type of system: El Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes O/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:
L S Lowell Waste Water
1o'—
Sign toe 17HaulerU Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
0 13
System Pumping c r
Form 4 r
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 front of house,(rq jlj nt o out left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, Wder deck.
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
'7C
Telephone Number
B. Pumping Record
1. Date of Pumping Da � 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Ce ool(s) ❑ Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? B<es ❑ No If yes, was it cleaned? es ❑ No
5. Condi I of
System:
L. c " ,..
r _
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. n where contents were disposed:
G.L.S.D. Lowe as Water
Signat re of auler Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping,Record tJ ?"115
Form 4
DEP has provided this form for usezby local Boards of Health. Other f"s may be used, but the
information-must be substantially the tame 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 left/Right rear of house, Left/right side of house, Left/
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
53 WtIV4(— Bvrc��
cityfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State� Zip Code
_7(?
Telephone Number
B. Pumping Rpcord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of systeft ❑ ' Cesspool(s) 3-9e-p-ilc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yap ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of'System:
A bA
\A, CLqAL- 6r)JF
6.- System Pumped By:
Nell.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location where contents-were disposed:
,.L S: Lowell Waste Water
I
'§ignAtu I Fe HauleV Date
t5form4.doc-06/03
System Pumping Record•Page 1 of 1