HomeMy WebLinkAboutSeptic Pumping Slip - 136 ROCKY BROOK ROAD 3/8/2016 Commonwealth of Massachusetts
u City/Town of
K
System i Record
Form 4
r
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�.'°L )RigIC rout of house Left/Right rear of house, Left/right side of house, Left/
Right side of butldirig,Left/Right fr6—rWbTbuilding, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
r.
Name
Address(if different from location)
City/Town State; Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) EYS tp ic Tank
El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No
5. Cond i#i o'r� of ys'f#yem: o\
6. System Pumpe By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company ,
7. Location where contents were disposed:
Gs S. Lowell Waste Water
SignAtufe 4 HaulerU Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
M u City/Town of � E D-
Form System Pumping Record
4 ) `1 ``(,i';�;
DEP has provided this form for use by local Boards FrjMHid0d)hbfW"6b(MF6F6)1J1 lth. Other forms m be used, but the
information must be substantially the same as that "th this form, check with your
local Board of Health tQ determine the form they us cord 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 hour Left..fro.D
g �; tof..hrrusQ Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address
w..
City/Town -- — State – — - Zip Code -- - --
2. System Owner: °" C4 ly�
------------------- --
Name -- ---
Address(if different from location)
City/Town StatEr Code
Telephone Number
B. Pumping ec®rd
1. Date of Pumping Date ----- -- ------- 2. Quantity Pumped: Gallons ------
3. Type of system: ❑ Cesspool(s) D-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-fN6 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:
L S. „,-- L w Waste Water
Signatur of a lei Date
t5form4.doc•06/03 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts
City/Town of I J�J N 4
System en Record
Form 4 �m
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 Location:
forms on the
computer,use
_
only the tab key Address --- - —--
to move Our ✓ �'- �11
CUfSOf-do not -- ---- -} --------- — --use the:return City/Town JJJ\\\ State Zip Code
key. 2. System Owner:
V\ �
Name - - - - - -
Address(i(different from location)
City/Town/Town . 0 `��_� Code -- --
y - -- --- - - --- Sta Zi
Telephone Number
B. Pumping Record
1. Date of Pumping Gate — — - 2. Quantity 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. Condit*o of System:
6. Syst'epPumpeq By
r ,
Nanne Vehicle License Number
Company
7. Locatio vhere ontents
re di p ed:
aeH 7
A-,
Si na' Date — - -
-
http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
t5form4.doca 08103 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
4
- ,
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
VVk
DATE PIIMPINC: QUANTITY PUMPED [" �� � GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES '+
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O'T'HER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: co
TOWN OF
SYSTEM PUMPING D
t"=F
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:le» left front of house)
P
r
I)ATI;OF PUMPING:
QUANTITY PUMPE IS o GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE Or, SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE'R
HEAVY GREASE BAFFLES I PLACE
FOOTS LEACHFIE LD►RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTBE R(E L
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: .L. Lowell Waste