HomeMy WebLinkAboutSeptic Pumping Slip - 296 RALEIGH TAVERN LANE 2/24/2016 Commonwealth u
City/Town of
b System Pumping,Record
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
1. System Location: Left/Right front of house _'Y Righear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �q ,
City/Town State Zip Code
2. System Owner: (,
�( ,: �r
Name'
Address(if different from location)
City/Town ' State Zip Code
�� lrli@0 Telephone Number w
B. r
u
Pumping Record
1. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ET Sep it c 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.Bates-on F5621
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo tiara sere contents were disposed:
Ui-LS-P Lowell Waste Water
d
Sign a ffiilulej Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth
City/Town
YS
' 014
Form
MEP has provided this form for use by local Boards of Wealth. ether 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 Wealth to determine the forrn they use. The System Dumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facility Information
1. System Location: Leff/Right front of hour , L ra Rig ea =oTbuilding,'e Left/right side of house, Left/
Right side of building, Left/Right front of bur ding, Left ig Under dick
Address
City/Town ` Mate Zip Code
2. System Owner:
fir)
Name
Address(if different from location)
Cityfrown ' Mate "r E dip �rde
Telephone Number " r
r,
B. Pumping Record
1. Cate of Pumping 2. Quantity Dumped:
Date 2.
i`
3. Type of system: Cesspool(s) eptic Tank Ej Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El `(es No If yes, was it cleaned? El 'des No
5. Condition of'System:
6. System Pumped By:
Nell Bates7on F5521
Name vehicle License Number
6ateson Enterprises Inc
Company
7. jSignt weer contents were disposed:
WHaule" Lowell Waste Water
Orate
t5forrM.doc•06/03 System Pumping Record-Page 1 of 1
Commonwealth f Massachusetts
City/Town of
I System Pumping r J
Form 4
CEP 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<pL 4./Righ e of house,-Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear Of building, Under deck
Address
,�.
City/Town State Zip Code
2. System Owner:
e
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 4 2 uantity Pumped: .rv'
Date Gallons
3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 4o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location-where contents were disposed:
Lowell Waste Water
4/[ -A
sign We e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
r
City/Town of
a W° System Pumping Record i`(II'
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
1. System Location: Left/Right front of house'Ce -/'Rigs"rear of hous,O;)Left/right side of house, Left/
Right side of building, Left/Right front of building, Left igh�"f'rear of building, Under deck
Address
City/Town State ipZ Code
�w
2. System Owner:
Name
Address(if different from location)
City/Town State Zip-Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ` Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) YSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes /Klo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
t' t'
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati,Q where contents were disposed:
�L S. Lowell Waste Water
Sign toe fHauleV Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Ommonwe Ith of Massachusetts
2
�
�,N' ���
City/Town of r m� �
M Pumping Record l(� rdOFNO� ',lpk �JR
HE i'i&.."N H 6��W�AR R1,^ii'.'NT
Form 4 ,µ „
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, e /Righ ear of house, Left/right side of house, Left/
Right side of building, Left/Right front of bul drag, Left/Right rear of building, Under deck
Address
Cityrrown N111 State Zip Code
2. System Owner: c-'- J C"� Ae
Name
Address(if different from location)
CitylTown State �.�a, Z,jp 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: .
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location_wh re contents were disposed:
G.L S.
7 Lowell Waste Water
Sign toe Haule Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
W City/Town of
System u in Record
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
1. S 5,tem--Lo t'on: Left front of house, right front of house, left side of house, right side of hour , lao
Clear of hou J , right rear of house, left side of building, right rear of building, under deck.
City/Town ------- Q"-.) State Zip Code ---
2. System Owner:
Name - — - ----
Address(if different from location)
City/Town State-) Zip Code
Telephone Number
B. Pumping cord
1. Date of Pumping Date 2. Givantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) �epticTank ❑ Tight Tank
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes ® o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f S�`stem:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locat*grl whe a contents were disposed:
.LS owellAA/psteWpter
Signa u of auler Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
Cornmonwealth of Massachusetts
City/Town cf N� EC"° I System i r
ru Form 4 .C�f);
5y8
p Y =Rfflqy(bei used "tDEP has rovrded this farm far use b local Boards of Health. Othe' f �'information must be substantially the same as that provided here. �tt a �"'eo with your
local Board of Health to determine the form they use. The System ump ni g 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 front left rear)eft sid of house)Right front, right rear, right side of house.
forms on the
computer,the tab key Addresso
only y ki ti
to move your
cursor-do not City/Town State Zip Code
use the return
key. -_--- 2. System Owner: f ,
L
Name ---
Address(if different from location)
Cit y[Town State Zip Code
Telephone Number
B. Pumping ecord
1. Date of Pumping Date 2. Quantity Pumped: Gal on
3. Type of system: Cesspool(s) - eptic Tank F1 Tight Tank
Other(describe): —
4. Effluent Tee Filter present? 0 Yes 0-00 If yes, was it cleaned? Yes No
5. Conditiqn of Syste
w
6. System Pumped By:
Neil Batesan F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatlorrwhere contents were disposed:
L.S.D ) Lowell Waste Water
Agn re ojfH u r Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
_ Commonwealth of Massachusetts
City/Town Of
System r
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Hoard of Health or other approving authority. .
A. Facility Information -- — ------
Important:
When filling out 1. System Locatioo
forms on the
computer, use -
_..
cursor do noty Address
use the return City/Town State / Zip Cade
key.
2. System Owner -'-`
Name 1 -- — — --- —
�,a w ,
Address(i(different from location) — --- — ---— --
Cityf town —---:—
State — --- - ----
ip Code"
Telephone_
Number
pumphlig Record
1. Date.of Pumping pate — 2. Quantity Pumped: Gallons ---
3. Type of system: ❑ Cessp001(s) [,J„optic Tank ❑ Tight Tank
❑ Other(describe) -- -- — --
4. Effluent flee Filter present? ❑ Yes ❑ IVb If es was it cleaned?
Y ❑ Yes`❑ No
Condition of System:
k ey
5. Conde
6. System P,7 ed By.
Number
�
"4 icle�,icense
Name � Vehicle �--�----— — . ----- --
Company —
7. Locati rr�vhere contents we -d sposed::
F
P —
Signs re uler bake — — - — ----
http://www.mass.gov/d p/w ter/approvals/t5forms.htm#inspect
t5form4.doc•06/03
System'Pumping Record•Page 1 of 1
OF
TOWN SYSTEM PUMPING RIECO
A.'rEa
SYSTEM OWNER c ADD +SS SYSTEM LOCATION
" ....�( ._
(example: ant of house)
,. . " �. GALLONS
DA'T'E 9�Ya'P�JMPI1`�C�; � �JAITITY PUMPED :
CESSPOOL: NO YES SEPT"TC T NO VES
NATURE OF STRVTCE° ROUTINE, EMERGENCY
OBSERVATIONS
GOOD I4EAVY EASE _ BAFFLES IN PLACE - -
ROOTS LEACITT!IELTD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(EXPLAIN)
SYSTEM PUMPE TD BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO, G.L.S.D Lowell Waste
TOWN OF
SYSTEM PUMPING RECORD
DATE: [L-S-0)
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example left front of house)
CkC
DATE O ING: QU ANTF PUMPITY PUMPE D : b O GALLONS
CESSPOOL: NO \)A��YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
—
OBSERVATIONS:
GOOD CONDITION FULL TO COVE'R
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(E XPLAIN)
sysTrm PumPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.Dn— Lowell Waste
TOWN OF NORTH ANDOVER
SYSTEM I
/F
f
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
Q ► ::
t
DATE OF PUMPING: 10 3
QUANTITY PUMPED I f., d")t"°) GALLON
CESSPOOL: NO YES SEPTIC TANK: NO YES y�
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LE ACHF MELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: a°"
commonwealth of Massachusetts
massac husetts
i�t�r ir1 Record
Systerrr Owner
Location
c
Date of Pumping: Quantity Pumped: gallons
Cesspool: No °° Yes U Septic 'Tank: No U Yes
System Pumped by: 97efrejaa e mrej License #
Contents transterrr'ed to : Greater Lawrence Sanitary District
[date: Inspector:
I�
FOR-N1 a - S1'STEti1 Pi..:.,1P ; SIR
&
f
Cornmonwealth of Massachusetts <
Massachusetts
System l ec r
}stem vvvner }stem Location
. ( 9(" rry
Date of Pumping: "� ::� " Quantity Pumped: � ���".����-)galIons
Cesspool: No Yes ❑ Septic Tank: No ❑ Yes El
S ystem Pumped by.- _.r � '"'" License #:
Contents transferred to:
Date — Inspector