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HomeMy WebLinkAboutSeptic Pumping Slip - 101 CROSSBOW LANE 2/1/2016 i Commonwealth of Massachusetts - - 4 City/Town of System u i Record mlky 5 0 10 Form 4 TOWN Of NOT ANDOVER DEP has provided this form for use by local Boards of Health. Other " T 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 of house, Right side of house, Left front of house, Right front of house, Left rear of howl Ig tt re ra of how Left rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stater ~� Zip Code Lk Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) © Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [D-I o If yes, was it cleaned? ❑ Yes ❑ No 5. Con lti, n of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: LAS. Lowell Waste Water qgl6ture of Haul r Date t5form4.doc•06/03 System Pumping Record>Page 1 of 1 i I Commonwealth of Massachusetts City/Town of I , . System Pumping Record wi"i 2 h��:� Form 4 A DEP has provided this form for use by local Boards of Health. The SyStei zi t�tttprr� Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: filling When System Location: forms trt use t 1. S St the tab key Address to m to move your cursor-do not City/Town use the:return State Zip Code .key. 2. System Owner: Name Address(if different from location). City/Town Stat — iD Code w 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 resent? ,., p ❑ Yes o If yes, was it cleaned? E] Yes ❑ Na 1 5. Condition of System: 6. System P mped 1 Name Vehicle License Number Company -- 7. Location here contents were d" osed: Signatur of ul Date http://www.mass.gov/diep/wale /ap rovals/t5forms.htm#inspect t5form4.doc•06!03 System Pumping Record•Page 1 of 1 Coil �wioryw alth of l�tsssacirusetts �t�rrn �'urnpinr Record System Ulvner System Location 7 C, . F 1 Date of Pumping: '� � C�uai�tily Pumped: � gatldt�� i Cesspool: No lr'es �.� Septic Talk No U Yes System 1'1►►nped by: radredert 54 mcd' License# Contents transl'errred to : Gieater tawrence Sanitary District Dale: _ _._ _--. lrlspector: