HomeMy WebLinkAboutSeptic Pumping Slip - 22 BANNAN DRIVE 12/18/2015 Commonwealth of Massachusetts
City/Town of
t Pumping ec r
Form 4
rom,q
tl 8 DEP has provided this form for use�by local Boards of Health. 1h6 l ut 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 t rear of hour , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear cif building, Under deck
Address q r
� U\
City(rown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town
Sta�� _ Zi. de
f
Telephone Number
- r
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Canons
r
3. Type of system': ❑ Cesspool(s) eptic Tank ❑ Tight Tank j
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® o If yes, was it cleaned? ❑ Yes ❑ No:
' 5. Condition of System:
1
6: System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises
Inc-
Company
7. Lo tiW re contents were disposed:
Cx L S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
N City/Town of ,t
a w° System Pumping Record
r Form 4
1
DEP has provided this form for use by local Boards of Health. grffpF►q,,s�jmay,4hwvsed but the
information must be substantially the same as that provided h reieft�ridi "thl ¢t , check with your
local Board of Health to determine the form they use. The Sys em�� umping 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 4g4 t rear of hous ft/right side of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping C) l ( Wuantity Pumped: I D
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:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G
S ,. ,. Lowell Waste Water
I A/0- t
Sign to'e I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts ❑
City/Town of
System Pumping Record - 2
Form 4
��l�AA
DEP has provided this form for use by local Boards of Heal W L 1 R","u"s 'd, but the
I'L
information must be substantially the same as that provide m, check with your
local Board of Health tQ 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 house, Right side of house, Left front of house, Right front of house,
Left rear of ho e'A kt
ig rear of ft rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner:
❑ � Q-6 0-A
Name
Address(if different from location)
City/Town State Z'Zip Code
-
Telephone Number
B. Pumping Record
(C-)
1. Date of Pumping Date 2. Quantity Pumped. Gallons
3. Type of system: ❑ Cesspool(s) 9-96-p—fic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑11 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#h-eir contents were disposed:
�
Lowe j)Was Water
Signature oddf H le Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
h
4
Commonwealth of Massachusetts n �
City/Town of
System Pumping Record �.�
Form 4 �v,e ro ANDOVER
V
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 side olAp, ht side of house, Left front of house, Right front of house,
Left rear of hou _I�._
ght rear of house �
Address
-:—)-a (?)
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
CityfFown State Zi 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 Ef No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: r
n D cjv'� � 4
6. System Pumped By:
Neil Bateson
Name Vehicle License Number F5821
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
D`7 Lowell Waste Water
S' n ur of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth ®f Massachusetts ,w
City/Town of
System Pumping Record
Form 4 AUG 1 �3 ?W)� 3
®formation must be substantially the same as that ®o provided here.'.Be�, �!srnyth s fpm;; he
p Y
y p i k with your
local Board of Health to determine the form they use. The System Pumping Record must""te ubmitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
y ..
When filling out 1. System Location: ��
forms on the �--- .� ��^ � �„„�J
computer,use
only the tab key Address
to move your C frown, C` V - r
cursor-do not " `
use the return � State Zip Code
key. 2. System Owner: w
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping ec r
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 o If yes, was it cleaned? ❑ Yes ❑ No
5. Condit'o of System:
. .
6. Syste P eo By
m / .
Name Vehicle License Number
Company
7. Locati where can ents w disposed:
Signat re Date
t5form4,doc•06/03 System Pumping Record^Page 1 of 1
i
I
Commonwealth of Massachusetts
f City/Town of `
t s
b i
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
Important: . S ste Lec,
p filling on: °
forms on the out 1 y t7) cation*
,... C C ., ...
computer, use
to move our
only the tab key Address
cursor-do not Cityfrown State Zip Code
use the return
key. 2. System Owner: \
VQ Name
man Address(if different from location)
Cit frown State / Zi Code
Telephone Number
'n Record
S � .f
_3
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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
I
6. System P mrrd By:
Name Vehicle License Number
Company
7. Location w i re content wire d' p ed:
-1711,
w4
Signatur dofpwr - Date
t5form4.doc^06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of I l
System Pumping cor APR �0 Nor r'006
Form 4
1.
I I
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. .
f
f
A. Facility Information
Important:
g y
When filling out System Location*
forms on the
computer,use
only the tab key Address
to move your _ . ti r� � + •. ..,,, ..,� ..__._ -C1 = � ..
cursor-do not City/Town
use the return State Zip Code
key. 2 System Owner:
Name
�I Address(i(different from location)
CitylTown State Zip 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 D—NO- ` If yes, was it cleaned? ❑ Yes ❑ No
5. Con ition of System' e
�, 'l�,_ •���-cam' �,.�
6. Syste Pumped Bye
Name m .. Vehicle License Number
Company --
7. Locatio where contents wer posed:
Si of o Hauler Date
http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
t5form4.doc-06103 System'Pumping Record•Page 1 of 1