HomeMy WebLinkAboutSeptic Pumping Slip - 1030 JOHNSON STREET 2/2/2016 Commonwealth �.v `� " �
n
City/Town of
Form 4
DEP has provided this form for us&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 roust be submitted to 1
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/Right front of hour ,�Lirh�lg,Rl �houso, Left/right side of house, Left/
Right side of building, Left/Right front of bul Left' i building, Under deck
Address
Citynown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State c 1pCode
Telephone Number
B. j
t,
Pumping r
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system. Cesspool(s) 0-80p`is nk El Tight Tank
El Other(describe):
4. Effluent Tee Filter present.? Cj Yes o If yes, was it cleaned? Yes No
5. Condition o KI tem: `
6. System Pumped By:
Neil Bateson F5621
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ti h re contents were disposed:
G L S. Lowell Waste Water
SignAtufe cf hiaule
Date
t5form4.doc®06103 System Pumping Record.Page 1 of 1
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Commonwealth of Massachusetts
City/Town of
System Pumping Record
p. A d H PAF,'W.NT Form 4
,m
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 a Rig rear of hour Left/right side of house, Left/
Right side of building, Left/ Right front of b '
di g, Left/Right rear of building, Under deck
Address 6) 6) �� r✓V� �Jc�"�� "� f?l QQ,.�� .
City/Town State Zip Code
2. System Owner:
t,>
Name
Address(if different from location)
City/Town State /-� � +Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0--geptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Syste :
r
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L76-L ati ere contents were disposed:
S. Lowell Waste Water
Sign toe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Massachusetts
P#V�~' ^��
City/Town v^o
System ��ump.n�� Rec��rd '5
Form 4 �
e NT
HEALTH DEPARTMENT
OEP has provided this form for use bv local Boards nf Health. <](herfommonnaybnused. buf�h�--
information must be,substantially the same as that provided here. Before using this form, 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 op'other approving authority.
A~ Facility Information
1. 8 house, Right side of house, Left front of house, Right hnntofhoune.
Right rear ofhouse. Left rear ofbuilding. Right rear ofbuilding.
Address
Qty/Town 0m»a Zip Code
2 �yobom {J�nar�
� �
Name
Address(if different from location)
Cityrrown Gtat
Telephone Number
B. ���NNK�~�� ������� �
~~~ Pumping" ~° "~~ ~~^
1. Date ofPumping Date 2. Quantity Pumped: oo|�ns
3. Type ofsystem: El Cesspool(s) Septic Tank Fl Tight Tank
L�
Other(describe):
4. Effluent Tee Filter present? El Yes [] No |f yes, was itcleaned? E] Yee Fl No
5. Conditign
V\" kew
fU14)
O. System Pumped By:
Nei| Bmteenn F5821
Name Vehicle License Number
8oieson Enterprises Inc
Company
7. L U
, _qre contents were disposed:
/,O-L.S.D LoweA Waste Water
Lf
Signature FKule( Date
mmnn4.doc-0603 System Pumping Record`Page 1o|1
1
Commonwealth of Massachusetts
City/Town of 1
w° System Pumping Record
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
Important:
When filling out 1. System Location: Left fron , ft reaq, left sid o� use t° ight front, right rear, right side of house.
forms on the
computer,use
only the tab key Address r
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
r� L�,
Name
" Address(if different from location)
City/Town 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 __ No If yes, was it cleaned? Yes ] No
5. Condition of System:
01-
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S.D' Lowell Waste Water
igna ure of H"r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1