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: