HomeMy WebLinkAboutSeptic Pumping Slip - 287 FOREST STREET 3/7/2016 Commonwealth of Massachusetts
= a City/Town of r'111V 20 ?LW
System 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 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 g/Right rear of house a ing, Und f hour , Left/
/righ�i
Right side of building, Left/Right front of building, Left/Right rear of build' r deck
Address c,
.. ��...�.��`.. A n
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown Statq,, iprCode
Telephone Number
B. Pumping ecor
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe);
4. Effluent Tee Filter present? ❑ Yes No r If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: (� A
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign toe cfHaule Date
t5form4.doc>06/08 System Pumping Record a Page 1 of 1
Commonwealth of Massachusetts
City/Town of
-_ System Pumping or
Form 4
'(�F1
DEP has provided this form for use by local Boards of Health. Other form nay uec, kt�t the
information must be substantially the same as that provided here. Before sin 6,"f witJ your
local Board of Health to determine the form they use. The System Pumpi g Record must be submi ed to
the local Board of Health or other approving authority.
A. Facility/ Information
1. System Location: Left front of house, right front of hous left'sldef Ise,right side oiouse, 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 State, C W) t �,tp-Code
Telephone Number
B. Pumping Record
1. Date of Pumping � — 2. Quantity Pumped:
Date Gallons
1 Type of system: ❑ Cesspool(s) 0 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 J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Locat!Gq where contents were disposed:
P/L.S.Q,,)/j Lowell ste ter
-� a - [C
Signa u of auler Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
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Commonwealth of Massachusetts
City/Town of I
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Th -Sysiiin�Pumpin'g'Re' cora 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
! .
computer,use
only the tab key Address t
to move your
cursor-do not
City/Town
use the return State Zip Code
key. 2. System Owner:
Name
'Address(if different from location)
City/Town State 7 Zip Code
)
Telephone Number
13. Pumping Record C11. _6
-y
( I's , 7 e,7
1. Date of Pumping
2. Quantity Pumped:
Pate Gallons
3. Type of system: ❑ Cesspool(s) 1c Tank ❑ Tight Tank
❑ Other(describe): —-----
4. Effluent Tee Filter present? ❑ Yes ff'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sys m:
T
(7
6. Syste Pumped B
Name Vehicle License Number
Company'
Locatio w ere ontents we,(e dispbled:
Sign re of aul r
Date
�n
http://www.mass.gov/dep/water/app'rovals/t5forms.htm#inspect
t5form4.doc•06103 System"Pumping Record •Page 1 of 1
TOWN OF
SYSTEM 1FA MPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
dNA(XC ftAb (example: left front of house)
51-
DATE OF PUMPING: �)-XIA QUANTITYPUMPED : 1 <j7') GALLONS
CESSPOOL: NO i YES SEPTIC TANK: NO- YES
NATURE, OF SERVICE: ROUTINE k/ EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACII MELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTI-I •R(EXPLAIN)
SYS'T'EM PUMPED BY: Bateson Enterprises, Inc.
CCD MME NTS:
CONTENTS TRANSFERRED TO: G.L.S.D--.,—/ Lowell Waste