Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 49 ORCHARD HILL ROAD 3/1/2016 Commonwealth x City/Town of Pumping System Form DEP has provided this form for use<by local Boards cf Health. Other forms may be bsed, 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. Facill.ty, 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 'on of building Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner: Y A . A,/4 Name' Address(if different from location) Citylrown ' State Zip Code ' Telephone Number B. Pumping Record ) - , .� _ 1. Date of Pumping Date 2. Quantity Pumped: Gallons V i 3. Type of system: ❑ Cesspool(s) eptk ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No; 5. Condition of Syste IV f 6: System Pumped By: Neil.Batesbn F5821 Name Vehicle License Number Bateson Ente!prises Inc- Company 7. Location where contents were disposed: Lowell Waste Water Sign t e Haule Date t5form4.doc•06/03 System Pumping Record*Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping er Form 4 U ��./� 63 't9':6"A d w K MEN r CEP has provided this farm 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,...Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/ 2ightl1rcrnt of building, Left/Right rear of building, Under deck Address � Cityll'ow � State�L Zip Code 2. System Owner: Name' AA-A- Address(if different from location) City/Town ' State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 1A 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: Nell Batesbn F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatiori'whare contents were disposed: .-aL S.Q Lowell Waste Water SignAtufa,$Haule Date t5form4.doc•06/03 System Pumping Record o Page 1 of 1 Commonwealth of Massachusetts City/Town of e System Pumping Form 4 DEP has provided this form for use by local Boards o 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 ront of buildiri 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 i Cede (.. �C Telephone Number B. r t t. Pumping Record 1. Date of Pumping `µ' 2. Quantity Pumped: -� Date Gallons 3. Type of system: ® Cesspool(s) ❑l.Se"ptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes a"N"'o A If yes, was it cleaned? ❑ Yes E Na 5. Condition of 4 UJ 6. System Pumped By: Nell Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lo cat' h re contents were disposed: a-- .. P °L S. Lowell Waste Water �n Sign t e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of Sys' tem 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 forrh they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information (L 1. System Location: Left/Righr-f6i66-66i-�-* 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 City/Town State Zip Code 2. System Owner: "A . P , i-A A ") V Name U Address(if different from location) Cityrrown State,-- --) Zip Code Telephone Number B. Pumping Record I. Date of Pumping If- Quantity Pumped: Date Gallons 3. Type of system: ❑ I Cesspool(s) ❑-Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? El Yes 1:1. "No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi of System: r)()W 6. System Pumped By: Nell Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company . 7. Location where contents were disposed: ,LAI;) Lowell Waste Water Sign toe Haule Date t5form4.doc•06103 System Pumping Record•Page 1 of I n x a :i C I:. p Commonwealth Of Massachusetts LN "°i� 011013 City/Town of gym:W mto l Il rd . � : N ii I M yye 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 Ahis 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 Informatti®n 1. System Location: Left/Right front of house,Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/ Righ §ril. f build nay, 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 Zi Code Telephone Number B. Pumping Record 1. Date of Pumping Date . Quantity Pumped; Gallons 3. Type of system: ❑ Cesspool(s) ® Sep it c Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter resent? '. p ❑ Yes ® No If yes, was it cleaned? F-1 Yes ❑ No 5. Condit�`on of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatwhere contents were disposed: G L Lowell Waste Water � , .3 ;Sign Date t5form4.doc•06/03 System Pumping Record>Page 1 of 1 Commonwealth of Massachusetts � r u City/Town Of b System Pumping r F®rrn 4 A, 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, Left/Right rear of house, Left/right side of house, Left/ Right side of building,Left/ igh �ront of buil m , Left/Right rear of building, Under deck Address / , % (A City/Town `" State Zip Code 2. System Owner; Name Address(if different from location) City/Town Sta i Ode Telephone Number B. Pumping Record 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 _ 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�jq,n ere contents were disposed: G.L S: Lowell Waste Water Sign toe I Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts mYaoyr.�anrili irniUii�i Oda�� ^y�,rr aiwa vAwawwvid w City/Town of � r��;� 2v�' x, System unpin eo r Form 4 '„F SVeJ4 DEP has provided this form for use by local Boards of Health. Other or��°d i n° ,� � t information must be substantially the same as that provided here. B !1T6W'� tt t tWtr rt t, ctt 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 ff&❑f h . se, right r_6 of house, left side of house, right side of house, Left `of��� rear of house, right rea , left sided67t bui iing” right rear of building, under deck. CitylTown State Zip Code 2. System Owner: A Name -- — ------- -— -- Address(if different from location) City/Town Statg Z"ode Telephone Number B. uming ecor ,N. 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 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: _ //U 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Lac ti here contents were disposed: L.S:D /40waWast er r 1. Signatur . f Vau& Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts _ per ��{pq py City/ 1 own o f uwwwimiwr uwn'wuuwuu+wumwimwwp a X System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other fa nl �i�ttt1a information must be substantially the same as that provided here. Be f a bpi 1ieram)"otri k Ith your local Board of Health to determine the form they use. The System Pumping Record mush a su mitted 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 house Ri ht rear qf house. L ft rear If buil in fight rear of building. Address City/Town State Zip Code 2. System Owner: - n ------------------- - — - - ----- ---------- Name - Address(if different from location) --- - ------------ -- City/Town Stat- -- Zip Cade ---- Telephone Number B. Pumping ecor r 1. Date of Pumping --- 2. Quantity Pumped: ------ --- Date Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): - 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condi is of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location.where contents were disposed: G.L.S.D Lowel ste er --------- - --- ------ --------------------- rf Signature of a by Date t5form4.doce 06/03 System Pumping Record.Page 1 of 1 1 Commonwealth of Massachusetts a City/Town ®f a System Pumping Record 6 M 5ye yydw Form 4 L DEP has provided this form for use by local Boards of Health. Otf r he information must be substantially the same as that provided here is orm, 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 house, Right rear of house. Left rear of buil ng Right rear of building. Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code CC)_ � �7 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o 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 where contents were disposed: D Lowell Waste Water ` g reof aul r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth Of Massachusetts City/Town of o System in Record Form 4 DP provided h Boards �herfarns mar �u d, but the fomationmust be substantially the same asthat p rovided h 9 e 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 of 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 h se ig4t rear of h se. L ilding. Ri ht rear of building. Address - - - . , � . Cityrrown -- - -- State Zip Code-- -- 2. System Owner: A - ----- ---- --------- -------- Name -- - - - - — -- ---- - Address(if different from(ocation) -- -- ----- - - -- ------- -- - Cityrrown Stat Ye� J Telepho a Number B. Pumping Record -- 1, Date of Pumping Date 2. Quantity ty Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): - - ----- - 4. Effluent Tee Filter present? ❑ Yes D'"No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: k L-- 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bate-son Enterprises Inc _ Company 7. ocati on..,w L sere contents were disposed: ^� '"G S. Lowell Waste Water ------ - ---------- Signature of Hauler p to t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts ........ ... City/Town ®f �� � ���'� H'r�� ww� w n � System Pumping Record MN( 2 6 2009 e` Form 4� DEP has provided this form for use by local Boards of Health. Ot � � ' FME4 bufi'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 Locatio Left fro pt-,)left rear, lef side of h rase. Mi ht fron r ht rear, right side of house. forms on the � ,, � computer, use -- only the tab key Address to move your � „� C :.✓� � � -�.., .a_w .-_w ,�. cursor-do not City/Town State Zip Code use the return key. 2. System Owner: 004 A P -_.-- Name -- Address(if different from location) City/Town State / -- o e—., . ' t '.. Telephone Number B. Pumping Record 1. Date of Pumping Date — Quantity Pumped: Gallons 3. Type of system: Cesspool(s) LA eptic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? Yes No If yes, was it cleaned? El Yes [j No 5. Condition of System: � t w_ ,7 6. System Pumped By: Neil Bateson _ F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location wl ere,contents were disposed: AL S.D } Lowell Waste Water C ure of H u r Date t5form4.doc>06/03 System Pumping Record^Page 1 of 1 IL Commonwealth ®f Massachusetts r City/Town of , ❑ System Pumping Record 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: When filling out 1. System cation: w forms on the computer, use only the tab key Address -- -- - / to move your ❑ (/❑ ..� /' ❑- - -�J cursor-do not City/Town - ---- - State Zip Code use the return key. 2. System Owner: VQ Name Address(if different from location) City/Town State Zip Co Y ..` P Telephone Number B. Pumping cor 1. Date of Pumping sate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ YesQ4o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition System: rr cl Y p y: 6, S stem u ed B r - Name jr e-hicle License Number Company 7. Location whe )contents were di ed: ~ ° Sig tur of auler ,. Date t5form4.doc-06/03 System Pumping Record 4 Page 1 of 1 Commonwealth of Massachusetts x !� 1 11"1 rd TOWN O N R I"I.t ANDOVER __ .. or wf HEALTH WB:" Form 4 . � G�4 Svy`y 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. System L ration: - forms on the ....... computer,use aae only the tab key -- cursor�doo your Address , r(.� .::. � —. ✓ C, .. - use the-return City/Town State Zip Code .key. 2. System Owner: VIQ Name — -- -- - - --- - - -- --- " Address(if different from location) — ---- - —"" -- ------- -- ---- CikyfTown State Zip Cod e Telephone Number B. Pumping Record 1. Date of Pumping g Date 2. Quantity Pumped: Gallons ..mow.. 3. Type of syskem: ❑ Cesspool(s) ESe pt is Tank- ❑ Tight Tank ❑ Other(describe): -- --- ----------- ---- -._"--- 4. Effluent Tee Filter present? ❑ Yes ❑-No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Syste Pumped By ° Name Vehicle license Number Company 7. Location fi&e contents d' sed: g _ .,. S re i na't o H ler Date --"http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect t5form4.doc^06/43 System Pumping Record.Page 1 of 1 TOWN OF SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED : 2 GALLONS CESSPOOL: NO S SEPTIC TANK: NO- YES NATURE, OF SERVICE: ROUTINE, EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVED HEAVY GREASE BAFFLES IN PLACE ROOTS LEACI4 ELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(E XPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: .L. .I) Waste- ltq TOWN OF NORTH ANDOVER SYSTEM DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF P'LJIlZI?ING: a A- -'j-4A'NTITY PUMPED `�� GALL,ONS CESSPOOL: NO . SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LE ACHF,IE LD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) q 4 SYSTEM PUMPED BY: v COMMENTS: CONTENTS TRANSFERRED TO: