HomeMy WebLinkAboutSeptic Pumping Slip - 29 WHITE BIRCH LANE 12/15/2015 Commonwealth of Massachusetts i I
City/Town of �
System Pumping Record ���°�`� ��
p ,
Form 4 `
4,M yV• I f
V
DEP has provided this form for use by local Boards�of Health., 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:
forms on the N
computer, use
cusoredonot .. .
only the tab key Address
to use the return City/Town "
State Zip Code
key.
2. System Owner:
VT"Wi
e
Name
Address(if different from location
CityfTown State m,
,� Zip Code
Telephone Number
B. Pumping Record
1. Date.of Pumping Date 2. Quantity Pumped:p Gallons
3. Type of system: ❑ Cesspool(s) ®— eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned?
El Yes ❑ No
5. Condition of System:
6. Sysrmpurnped By
's
Name Vehicle License Number
Company
. _
ocatio lmwh
ere contents,were f osed:
Sigpaturgrof H uler Date
h.ftp://www.mass.gov/dep/waterlapproval8/t5forms.htm#inspect
t5form4.doc•08/03
System'Pumping Record•Page 1 of 1
1
Commonwealth of Massachusefts
u City/Town of
System Pumping, Record
u
For t
g 4
v
f �,, 11�rtrsilfCVllifl,,, �
®EP has provided this form for use,by local Boards of Health. Other forms may be'used, but the 1
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the forth 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 hour Lr /Rig ar o hoe, Left/right side of house, Left/
Right side of building, Left/Right front of bul ding, Left/Right rear of building, Under deck
Address � .�J`°' `°"� �°� � 4 � �C �' ®°'Ch.'� „�✓
City/Town Mate Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown Stater , r Z*Code
Telephone Plumber 4
B. Pumping Record
1. Date of Pumping ®ate 2. Quantity Pumped:
Gallons
3. Type of system: El Cesspool(s) eptic Tank Ej Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Yes ETIN—o If yes, was it cleaned? Yes No
5. Conditio o S stern:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Plumber
Bateson Enterprises Inc'
Company
7. Locate contents were disposed:
Isign Lowell Waste Water
Date )
t5form4.doc•06/03 System Pumping Record®Page 1 of 1