HomeMy WebLinkAboutSeptic Pumping Slip - 93 WINTERGREEN DRIVE 2/25/2016 vaww.uowmon,,:.m "" � vwawr'
Commonwealth of Massachusetts i IV ���
u W ity/Town of
System Pumping Record
Form 4 Ha �e. p..�a 1 °
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 farm 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�` L #(t,>Right(f�ot of_house"Left/Right rear of house, Left/right side of house, Left/
Right side of builft§, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town �— State Zip Code
2. System Owner: A
Name l
Address(if different from location)
City/Town State pode
C"
Telephone Number
B. Pumping Record
1. Date of Pumping date 2. afitity Pumped;
Lallans
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. ConditioSystem:��'�` �� �-:�. �. ,1,� ,. �"�. ���."�`.�...•�S
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
_L S. Lowell Waste Water
"_3
Sign toe HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
_ Commonwealth of Massachusetts �
City/-Town Of JR F Aar
EHEJALTH E A T E u 11 r D
v
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 of other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, fgront of h0usel'�ight front of house,
9 _.
Right p , Left rear of building. Ri ht rear ofbu'ding.
Left rear of house, Ri hit re—ar o house. ---------------------------
Address
City(rown
----- ' -- - — State Zip Code
2. System Owner:
Name --------- --- ----
Address(if different from location)
-- ------- --------
Cit /Town State Zip Code
Telephone Number
B. Pumping Record
Date Ga
1. Date of Pumping - - 2. Quantity Pumped: — llons
-- —
3. Type of system: F] Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): -----------
-----------------
4. Effluent Tee Filter present? ❑ Yes Ms' o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bate_son __ _ -- F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Location where contents were disposed:
....................
Lowell Waste Water — __—__— ---
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts [ �' ��.. . �I
a City/Town of MAY
System U in Record
4�PE MI Ti I)u..i ARI' E T.I�
Form 4 u� WN OF r�01FU H NDU
Information must be substantial) the same as that provided here. Before.. i g..
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
y p e usin 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
When filling out 1. System Location.(Left front eft rear, left side of house. Right front, right rear, right side of house.
forms on the –
computer, use (.. ( a, —only the tab key Address �I
to move your ,�� 0 s�
cursor-do not City/Town State Zip Code
use the return y
key. 2. System Owner:
-- -- e.
R Name
Address(if different from location)
Citylrown -State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. .Quantity Pumped: Gallons
3. Type of system: 0 Cesspool(s) _/Septic Tank Tight Tank
[ Other(describe):
4. Effluent Tee Filter present? [j Yes L4/No If yes, was it cleaned? Yes Na
5. Condition of System:
_�NAO��A
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L_S_D---- Lowell Waste Water
igna ure of H"r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
O��rr onw lth Of Massachusetts
—- City/Town
Pumping System r
Form
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: n_ -, `` 1 ,,,t
When ms on the out 1 Syste L atio
filling
0
computer,use ------ -- -only the tab key Address — —
to move your
cursor-do not Cityfrown -- State Zip Code —
use the return
key. 2. System Owner: a
Name
Address(if different from location)
-- - ---- State w
Zip Code
City/Tawn ���w
Telephone Number
B. Pumping ec r
1. Date of Pumping Date 2. Quantity Pumped, Gallons -
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System u ped By:
Vehicle License Number
Name -
Company
7. Location pre contents„wer i posed:
Signatu a ler Date
t5form4.doc•06/03 System Pumping Record^Page 1 of 1
a
Commonwealth of Massachusetts
_ City/Town of I j
System' Pumping r � AM, t li
Form 4 .
DEP has provided this form for use by local Boards of Health. 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. Syst m Loca on w
forms on the
.. � .
computer,use
only the tab key Address --
to move your .. " ,.,
--
cursor-do not -��„ -- —
use the-return City/Town State Zip Code
key.
2. System Owner: , am
Name - --- - ----- -
rear --- -----
Address(if different from location) - - '1
-----------
Citylrown - State --- — -
—
Telephone Number
13. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped: --
Gallons
3. Type of system: ❑ Cesspool(s) k tic Tank ❑ Tight Tank
❑ Other(describe): -- -
4. Effluent Tee Filter present? ❑ Yes E1160 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition plIte�: / 17�".C' N, -
�.
6. System trmyed y
Name Vehicle i-icense Number
Company — w
7. Location here ca ten! -#ere osed:
Signs' re of er -- Date — -
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF
.. ..
SYSTEM PUMPING RECORD GE"NED
DATE: (t/—j
SYS'T'EM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of Douse)
DATE®F PTJ ING: c' QUANTITY PI1 ED : GALLONS
CESSPOOL: N® YES SEPTIC TANK: NO YES
NATURE, OF SERVICE: ROUTINE, EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACEIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(EXPLAIN)
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CON'TEN'TS TRANSFE ED'TO: G.L.S.ID Lovell WaSte