HomeMy WebLinkAboutSeptic Pumping Slip - 52 BANNAN DRIVE 12/18/2015 J
Commonwealth of Massachusetts
{
City /Town of
a System Pumping Record
w4
Form 4
F
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 housed righ�de of hoous-e Left/
Right side of building, Left/Right front of building, Left/Right rear of�sgt11 g, Under dec
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City town Sta 7i Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [3-9eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condistiorl of System: A
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
61 S. Lowell Waste Water
WaA
Sign toe Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM PUMPING RECO
DATE° ,� ,g
SYSTEM OWNER ADDRESS SYSTEM LOCATION
(example: left front o f house
14-j-
(?-X,�AV',C) VA
l `
DATE OF PUMPING: �`"" I t -o�2 QUANTITY PUMPED : GALL NS
CESSPOOL: NO YES SE IC T a NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OT R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFE PMED TO, G.L.S.D Lowell Waste
I
1
Commonwealth ®f Massachusetts
CityfTown of _
System unpin eeord a
Form 4
f
DEP has provided this form for use by local Boards of Health.Other form ,may�be used,but the J
information must be substantially the same as that provided here. Before'using this form,check withl 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 tilling out 1. System L cation
forms on the
computer, use
only the tab key Address -
to move your 6,-ZN1 A V\
cursor-do not City/Town state Zip Code
use the return
key. 2. System Owner:
tab 4
Name
Address(if different from Nation)
Citylrown St _ Lf ,Code
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 [3-k' � If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System-y '. So
6. System Ciped By: -
Name > Vehicle License Number
Company
7. Location w�tere coat is disposed:
Signature Hq Date
t5form4.doc-06103 System Pumping Record•Page 1 of 1
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