HomeMy WebLinkAboutSeptic Pumping Slip - 90 WINDSOR LANE 3/3/2016 Conimonwealth
s -fown of
System Pumping Record
Form 4
D P 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/ i Mne--Mwk-"'ide of house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, "'
,address ��
Cityfrown State Zip Cade
2. System Owner:
Name'
Address(if di Brent from,location)
citylrown Mate ode
rJr ', U 1 20114
Telephone Number
1
B. Pumping Record
1. Date of Pumping o�te 2. Quantity Pumped:
Lallans
3. Type of system: Cesspool(s) eptic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? Ej Yes No
5. Condition of s m:
6. System Pumped By:
Neil Batesan F5821
Name Vehicle License dumber
Bateson Enterprises Inc
company
7. Lo tion.:wiere ontents were disposed:
aL Lowell Waste Water
Sign to a Flaule date
t5form4.doc-06/03 System Pumping Record m Page 1 of 1
Commonwealth chu tt
lug
City/Town of
Pumping S item YS
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. c ility Information
I. System Location: Left/Right front of house, Left/Right rear of house, Le right s de of hQua%eLeft/
Right side of building, Left/Right front of building, Left/Right rear Of building, Under deck
Address 1 L-v\ I'Jn,,14�
City/Town Mate Zip Code
2. System owner:
Name'
Address(if different from location)
Cityrrown Slat Zip Code
C?iT
Telephone Number
B. _ 1
Pumping Record
� --
1. Date of Pumping Yale 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank Tight Tank
❑ other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No,
" 5. Conr of System:
6. System Pumped By:
Neil Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc, .� d. C4'�
Company
7. Location w re contents were disposed:
Lowell Waste Water
SIgnkufe I Houle Date
t5form4.doc•06103 system Pumping Record.Page 1 of 1
Commonwealth ®f Massachusetts �Y . .
x
City/Town Of
;
System Pumping Record
rOWN Or NO III°B NDr ANDOVER
Form 4 f iE L 7e 11 l'Yfl..mFBr�::
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 : ht side of house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under de—&—"
Address LV f, ,._.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State �.� q Code
t ...�
Telephone Number
B. Pumping ecor
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 ( Na .,.
If yes, was it cleaned? E] Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loo where contents were disposed:
r
G.L S. Lowell Waste Water
Sign toe Haule Date
t5form4.doc•06/08 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
--
City/Town of
t u a� r . I ern 01
= Form 4
GAs
I'M CO NO P�AND k
DEP has provided this form for use by local Boards of Health. Oth r f Ojtut he
information must be substantially the same as that provided here. Be ore using is o , c ck 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 front of house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name --- — --- ----- -
Address(if different from location)
City/Town Sta m ip Code --- ----
Telephone Number
B. Pumping ecor
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 9-90 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S stem:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locatio w ere contents were disposed:
S L well Wast r
Signat re H uler Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth f Massachusetts
RECEIVED
_ d
City/Town of awl d: T 20 Cd9 J
System Pumping Record
Form 4 l EAL n-...D EPARTMENT
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 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 hou Right side of
y g hous_e,_„L`bft front of house, Right front of house,
Left rear of house, Right rear of house.Left rear of building. Right rear of building.
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
-
City/Town Stag
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. Lon-wh a contents were disposed:
7.S.D Lowell Waste Water
Signature of Hauler date
t5form4.doc•06/03 System Pumping Record>Page 1 of 1
Commonwealth t Massachusetts
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�fisJorm; check with your,
local Board of Health to determine the form they use. The System Pumping Recordi must be submitted
the local Board of Health or other approving authority.
A. Facility Information
Important: ;1 - �,. ), _
When filling out 1. System Locatio ;
forms on the .
computer, use
only the tab key Address
to move your
cursor- not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
" Address(if different from location)
City/Town State . p.._� Zip Co de} ""
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) G eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes p.-No� �~ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition qf System:
i
& System Purn By:
t
Name ` Vehicle License Number
S � G
Company
�
�
7. Location h" re contents were tsposed:
Signature H#Iert Date
t5form4"doc4 06/03 System Pumping Record o Page 1 of 1
Commonwealth of Massachusetts
City/Town of �,w„1"iV
I ��
System Pumping Record
Form 4 w. L 7 �
4
DEP has provided this form for use by local Boards of Health 1 I y #airw:Ptira�g cord must
be submitted to the local Board of Health or other approving authority.
A. Facility Information --
Important:
When filling out 1. System Location
forms on the � t�.", � C--� �- (—, (: V C �,1 `,> �:
computer, use �... �._
only the tab key Address
to move your
cursor-do not !Yawn
Cwt - - -
use the--return y State Zip Code
key. 2. System Owner:
Name - ---- — --- --- - - —
Address(if different from location)
City/Town St Zip Code
Telephone Number�
. Pumping (Record —
w.
1. Date of Pumping pate — 2. Quantity Pumped: ---- -
Gallons
3. Type of system: ❑ Cesspool(s) Q meptic Tank ❑ Tight Tank
❑ Other(describe): - - -
4. Effluent Tee Filter present? ❑ Yes ❑E°
Na If yes, was it cleaned? E] Yes ❑ Na
5. Condition of System:
6. S st m Pumped B
:._ t _
;Name - ------ -
Vehicle License Number — T
Company — ------ – -—
f N , C were di d:
7, Locatia where contents
SignAure N ler Date —
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5forrn4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massy chusetts
V/; Massachusetts
System Pu p
, icing Racgird_
� ..
V 7
System Owner � � System Location
�W
r
Date of Pumping: f (� .._ ;.� �:,. (71'
7 Quantity Pumped: allons
Cesspool: o [�:], ° Septic �l
' Yc�s [.� S� tip:�I'nrw�: No Yes
System Pumped by: c ' W License#
Contents transferred to: Greater Lawrence Sanitary W i t
Date:
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
�dwctcok'
q o W I'VA06C
DATE OF PUMPING: 1 QUANTITY PUMPED : IV 5y GALLONS
CESSPOOL: NO V 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 CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CON'T'ENTS TRANSFERRED TO:
Conn ionwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
}
VA,
Date of Pumping: Quantity Pumped: 'gallons
Cesspool: No Yes L) Septic Tank: No U Yes H---
System Pumped by: Lctredea Srf&,tf tined License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector:
