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HomeMy WebLinkAboutSeptic Pumping Slip - 75 LOST POND LANE 2/1/2016 I Commonwealth of Massachusetts City/Town of M Iyte Pumping 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 Locatio Le( ig or n—of'hous , Left/Right rear of house, Left/right side of house, Left/ Right side of bul Wig, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner: . Name Address(if different from location) City/Town St Ap Code � . Telephone Number B. Pumping Record 1. Date of Pumping 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. Condi 'on pf System: C�COQ 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc' Company , 7. Location where contents were disposed: CaL S. Lowell Waste Water - C Sign toe I HaulerU Date t5form4.doc•06103 System Pumping Record.Page 1 of 1 i 1 Commonwealth of Massachusetts �� City/Town of , System pin Record JUL a Form 4� R ovvq ��,.. .. ' :� DEP has provided this form for use b local Boards of Health. Other fo nn m Information must be substantially the same as that provided here. Before using this form,but the a bee 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: g y LOCati N When fillip out 1. S St forms on the computer, use only the tab key Address C to move your .. cursor-do not City/Town State Zip Code use the return key. 2. System Owner: Name n Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping c 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 o If yes, was it cleaned? ❑ Yes ❑ No 5, Condition of S tern: \ ��ca vv) t tj2x�04 6. Syste P roped By: { R-= Name Vehicle License Number Company 7. Location re r¢4nten! re(dis o sed: Signature H er Date t5form4.doce 06/03 System Pumping Record m Page 1 of 1 i I TOWN OF -A- oddv-eL- i SYSTEM PUMPING RECORD DATE: �l ` SYSTEM OWNER & ADDRESS SYSTEM LOCATION "P (example:left front of house) t DATE OF PUMPING: a�g- QUANTITY PUMPED : I �CC���� GALLONS CESSPOOL,: NO YES PTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIE L,D RUNBACK EXCESSIVE' SOLIDS FLOODED SOLIDS CARRYOVER O R(EXPLAIN) SYSTT*M PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFE RRE D TO: i i Commonwealth ot'Massachusetts Massachusetts I SVsteril Pumping Record System Owner System Locatioea Date of Pumping: �� 7 Quantity Pumped: C) gallons Cesspool: No Yes Septic 'Tank: No Yes System Pumped by: are'dort goAnhpimed License # Contents transperrred to : Greater Lawrence Sanitary District Date: _ Inspector s, �, I