HomeMy WebLinkAboutSeptic Pumping Slip - 146 DEER MEADOW ROAD 2/24/2016 Commonwealth f Massachusetts R E(,,3i"""I l,'
_ City/Town Of
" item YS
u in - r
For �'a�°�� C,)F H r�,a a VEF,`,
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. In r tics
1. System Location: Le 4 ti ont of hous , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left i Flight ronfof 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 State p pde ;
Telephone Number
B. Pumping Record �
1. hate of Pumping ®ate Z Quantity Pumped: Gallons Y
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 F5321
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locates ere contents were disposed:
G L S. Lowell Waste Water
�r
Sign t fe-j—HauleV Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
u City/Town of
System Pumping, Record
Form 4
DEP has provided this form for use4by 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, Left/Right rear 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
�, 1,..""p� �r�, ..._,/'�^��..",✓�'"_ � ,"'Cf.�..;�..�_"'�,'°'<" -,{�,.� „��,�,•,,.~� .,,,+„w: .mil„,,,,.:"yam .M��:'�,.,,'�
City/Town State Zip Code
2. System Owner:
Name.
Address(if different from location)
Citylrown State A —,�Zlp Cade
tt Telephone Number
B. N
t•
Pumping Record
1. Date of Pumping cafe 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) B Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yap ❑ 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. Laca` w,n- dre contents were disposed:
G.L S: Lowell Waste Water
Sign tufe qt Haule Date
t5form4.doca 06/03 System Pumping Record a Page 1 of 1
Commonwealth
System Pumping Record
p
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: Le i c nt of hp �, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Fight front of building, Left/Right rear(if building, Under deck
Address
�, " _.__. r .
City/Town State Zip Cade
2. System Owner:
(Name
Address(if different from location)
�� ' .f� n.�. State , Zip Cade
,f
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. C�uanti Pumped: Gallons
3. Type of system: Cesspool(s) Septic Tank El Tight Tank
El Other(describe): w.
4. Effluent Tee Filter present? El Ye No If yes, was it cleaned? Ej Yes Ej No,
5. Condition of S stem:
. System Pumped By:
Nell Sateson F5821
(Name Vehicle License(dumber
Sateson Enterprises Inc
company
7. Location where contents were disposed:
S Lowell Taste Water
a
Sign t e Houle Date
t5form4.docm 06/03 System bumping Record m Page 1 of 1
Commonwealth Of Mas
City own of
System Pumping Rec
DEP has provided this form for use l ) ) farms may be used, but the
P
information must be substantially the������,..� __ ,fore 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�ight front of ho , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Le 7Rig�h` 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/rown State Zip Code
Telephone Number "
B. Pumping er
Date „µµ^ p Gallons
1. Date of Pumping 2. Quantity Pumped:
3. Type of system; ® Cesspool(s) ED-Septic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes iJo If yes, was it cleaned? ® Yes ® No.
5. Condition of Syste :
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L 5: Lowell Waste Water
Sign t e Houle Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
u City/Town of
A
a
A System Pumping
.�` Form 4 0 l w
DEP has provided this form for use by local Boards of Health. Chth6r k#� r I jYi "f � but the
information must be substantially the same as that provided h rem,. i� `r �-w64 Og.� or , 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, Left/Right rear 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
tie
a2k -
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City[Town State Cade
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) epti
Sc 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. Loc ion- re contents were disposed:
Lowell Waste Water
W �
Sign toe I HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
City/Town of
a
Pumping System r
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: Lefl Right'=fratat of hauseLeft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right fron of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
d ik
2. System Owner:
Llca-
Name
Address(if different from location) 1 �;
City/Town State Zip Code
Telephone Number
B. Pumping Record
L! w... � ,.. I
1. Date of Pumping 4 r 2.. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) 19 Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes � No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
-L,Ao 6,c�e cl
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
�,.
gn #u a Houle Date V
si
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts NAM III m m E
City/Town of M AY � 6,
System Pumping r �„i l iD� D A� r. � �1
Form 4 A �w
,
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 farm, 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
When filling 1. System Location: Left front left rear, left side of house RI ht front„ ht rear ri ht sled of .,,,,
Important: l
g Y ci 9 9 hrause„
computer, use
only the tab key Address y f 1
q
to move our
y
cursor-do not Ci /Town State..�. i1' �...,�.°�� - ~--” .° � �,,,� 4,•. �;
ty Zip Code
use the return
key. 2. System Owner:
---- Name -
Address(if different from location)
- ,--) � �,. £ p Cgde
City/Town �e^� i
tat
Telephone Number
B. Pumping Record _.
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: 0 Cesspool(s) [j' eptic Tank Tight Tank
Other(describe): —
4. Effluent Tee Filter present? [j Yes No If yes, was it cleaned? p Yes No
5. Condit) n of Systerr
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca 'otere contents were disposed:
Lowell Waste Water
0: —� ✓ u /
igna ure of H u r Date
t5form4.doc°06/03 System Pumping Record°Page 1 of 1
Commonwealth of Massachusetts
z
CityfTown of
I r TO /i<(fl H O� �I a� VL r �w...
System in r
Form 4
DEP has provided this form for use by local Boards of Wealth. The System Pumping Record must
be submitted to the local Board of Wealth or other approving authority. -
Facility Information - -
Important:
When filling out 1. System Location: , ,r �i.a
forms an the
computer, use "
,.
only the tab key Address to move your y — Skates '
cursor-do not Cit /Town use kh&return Zip Code
key. 2. System Owner:
Name -- --- — - - - - - —
F°" Address(if different from location)
--- -— — - ------ - - —
City/Town State Zip Code
,-� ,
Telephone Number
Plumping Record
..
1. Date of Pumping oats 2. Quantity Pumped. Gallons
3.3. T e of s stem: ❑ Cesspool(s) � t
Yp Y ❑~°Sepic Tank El Tight Tank
❑ Other(describe): - ----"
4. Effluent Tee Filter present? ❑ Yes D"No! If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy tern;
6. System Pufm ped By;
Name Vehicle License Number
,µ
-
Company
7. Location wh a contents were di d:
Sign re f auler Date
http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
t5form4.doc•06103 System Pumping Record•Page 1 of 1
SYSTEM TOWN OF
I
DATE: ... .. c° '
SYSTEM OWNER & ADDRESS_ SYSTEM LOCATION
(example: left front of hawses)
DATEOFPUMPING: QUANTITY PUMPED : GALLONS
M �
CESSPOOL: NO � YES SEPTIC TANK: NO YES r. �
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES M PLACE
ROOTS LEACH IELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R. OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
Commomvealdi ofMassachuse(ts
Massachusetts
$yAtekn Illy Yn.pLqg__Lj-p cord
sy9teill Owner System Location
Quafitity Pumped: gallons
Date of I
Cesspool: No I-d" Ves I.'.) SepticTatik: No Yes
System himped by: Felredea Sfee ftiW License #
CoWentstimisficirredto : Greater qwellcesn".ftp y D9!!trA
Date: Inspector.
Commonwealth of Massachusetts
McasgLch tsetts
System
ystem Owner _ � System.Location
Date of Pumping: � ��� � ' Quantity Pumped: ���� 0 gallons
1,�, mul: No Yes S-Q.pjjgjMM: No Yes
System Pumped by: Fawdot License,
Contents tra.nsferrred to : Greater Lawrence 'unitary District
Date: Inspector:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: 4- _QUANTITY PUMPED 1. R-5-c) GALLONS
CESSPOOL: NO YES S .PTIC TANK: NO YES i
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: C l
TOWN OF
V l V1
SYSTEM PUMPING RECO"
DATE: ( - +
SYSTEM OWNER& ADD RE SS SYSTEM LGCATI®N
(example: left front of house)
. . 6 �1.
HATE OF PUMPING: ?Lt QUANTITY P ED : (. <�)0Q GALLONS
CESSPOOL: NO YES SEPTIC 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 CARRYOVE R OTHE R(E L
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: .L. . Lowell ante