HomeMy WebLinkAboutSeptic Pumping Slip - 44 CARLTON LANE 1/20/2016 i
Commonwealth E d
City/Town
YS
Form
,vt-4(k N l'M ANraOVAR
EAL7LI p6 A M 2uii�,
®EP has provided this fora for us&by local Boards 'of Health. Other �r� may a used, d tie
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 hous , eft/ gh rear®f hou , Left/right side of house, Left/
Right side of building, Left/Right front of b t n�, Left 6f building, Under deck
Address LA f
Gityfrown state dip Code
2. System Owner: I I G' h
Flame' `
Address(if different from location)
Cityrrown ' Stag C de
Telephone Plumber
_ E
B. Pumping ec r �
1. Date of Pumping Date 2ntity Pumped: Gallons
3. Type of system: Cesspool(s) STank ® Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yep No If yes, was it cleaned? Yes No.
" 5. Condition of tern:
6. System Pumped By:
Neil Batesion F5621
Name Vehicle License Plumber
Bateson Enterprises Inc
company
7. Location where contents were disposed:
GL LS.. Lowell Waste Water
a.
Hauls Date
t6form4.doca 06/03 System Pumping Record®Page 1 of 1
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Commonwealth of Massachusetts U
City/Town of
System Pumping Record
Form 4 G(�` N �'�,�� ["k
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. Syst m Location: -
forms on the ��
computer,use _
only the tab key Address
to move your V
C t
cursor-do not Cik /Town � A�
use the-return y State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
Cityfrown State
�����„�..„, _ Zip Code'
"
Telephone Number
B. Pumping Record
�.--
1 Date of Pump' tit Pumped:
ate
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. Conditio of System:I
s
6. Syste P mpeoBy"
Name Vehicle license Number
Company
7. Location ere contents ere ased:
Signatu of H ler D_ ate
http://www.mass.gov/dep/water/a provalg/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Re.I cord•Page 1 of 1
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TOWN
SYSTEM PUMPING RECO"
r
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
A KC.)
DATE OF PUMPING: QUANTITY P ED : GALLONS
CESSPOOL: NO YES SIEPTIC TANK: 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, OTBER(EXPLAIN)
sYsTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
' L
CONTENTS TRANSFERRED TO: 6-
COMM I) c Itla ot`Nlassacbusetts
-- , Mass ccltusctIs
1
System P"" Record
Systerrt O%veer System Location
Date of t'umping: °` (Quantity Pumped: 4 gallons
Cesspool: No Yes L_1 Septic Tank: No L.J Yes
System Pumped by: Fdrelart gfi ided License
Contents transterrred to : Greater Lawrence santt�ry �tatrlct
Date: _—_-- — — Inspector