HomeMy WebLinkAboutSeptic Pumping Slip - 101 ROCKY BROOK ROAD 3/8/2016 Commonwealth of Massachusetts �R ,°41 1
City/Town of
Pumping System Record
�«'�VN ,) NU �rt��ru,�,���it
Form 4
yv i'ri AI !I 1 i:q Flf�R lOf l Y I ;
DEP 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 Ring.�L Rig front of hoes Left/Right rear of house, Left/right side of house, Left/
Right side of buil eft/R ight front of building, Left/Right rear of building, Under deck
Address A � �••,
City/Town c4 State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown Stat
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity ty Pumped;pate C
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0"No If yes, was it cleaned? ❑ Yes ❑ No
5. Condit' n stem:
fi - . l --
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 7G.ion-where contents were disposed:
.,,
IL S. Lowell Waste Water
Sign toe cfHauleV Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
-
FHLE,�ALI*Ff'�., •°'`" CIN
� 1i 7 1,0@O
System Pumping Record
Form 4 TOWN NORTH AND VER
>
DEPARTMENT
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 or other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of hou Left frost cf Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address -
0 r , �, > ".
City[Town State Zip Code
2. System Owner:
-----------
Name
Address(if differen#from location)
- ---- ------ --
City/Town ------ -- S#ate 1� ----- -Zip Code
Telephone Number
B. Pumping ecr
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 IA°"Nlo If yes, was it cleaned? ❑ Yes ❑ No
5. Condi 'on f System:
E
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.L.S_.__ Lo ell aste YVater
------------
Signatu of a 10 Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth f Massachusetts
System 6
Form 4 re�a
i-�I���'�b9 E l P V 1k','.f f '.""
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 hare. 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: 1. S y ste Lacat
When filling out
farms an the
computer, use
only the tab key Address
to mane your � � "
a
�__
cursor-do not Citylrawn �� Stye Zip Code
use the return „, .”
key.
�� 2. System Owner: \\ Iw„ �..... .. M....(..
Blame - ----- —
Address(if different from location)
CityCrown State Zip Code
Telephone Number
B. Pumping car
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 Ej-K6 If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
A C
@V C..,�.��....(,�4d'^'�....,iP„��,„,,,t^� �.,.,� .P k�°�.«m��'"q lw
6. System Pumped B
a�
Name��, Vehicle License Number
Company
.
7. oca4 contents e disposed:
, ere cat
ww.. a-
r.�
Signattfre of Fla ler Date
t5form4,docm 06/03 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts � E
r Cityffown of I
Pump' Record
System ling
Form 4
BEP 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 Location
tl
forms on the
computer, :, -
- —— —
only to mov ure .. - .—.—�.---
to move do not Address ✓
use the return City/Town State_ Zip Code• -- �✓
_�
key.
2. System Owner
Name — -------- - ------ ---—
Ron —. -----— ----—----- —— — ------
Adtlress(if different from location)
City/Town --—
-- - ------ ----------
State, ) �'>a tµ Zip Code
Telephone Number
B. Pumping Record
1. Date.of Pumping
p g Date — — — 2. Quantity Pumped: Gallons — — --
3, Type of system: ❑ Cesspool(s) ❑--se°ptic Tan.k ❑ Tight Tank
❑ Other(describe): — --- -- ----
p ❑ Yes ❑-1 ,..,,....
4. Effluent Tee Filter resents o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
r
Y Loped By
6. S st m Pu
N_ame Vehicle License Number
--
Company,_`------ -----
n}where contents were posed:
Location �
p
Si tia o Houle
r Date ---- — — ------
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03
System'Pumping Record•Page 1 of 1
TOWN OF
I S w.
DATE: 9 OCT 1 9 2004,
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: front of'house)
(6 �c �
DATE OF PUMPING: � QUANTITY PUMPEID : ��� � GALLONS
CESSPOOL: NO ES SEPTIC T NO YES
NATURE IMF SERVICE: ROUTINE c- EMERGENCY
OBSERVATIONS:
GOOD CONIDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELID RU ACID
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMM4 NTS:
CONTENTS TRANSFERRED TAD: L. . L
Drell Waste
TOWN OF NORTH ANDOVER
SYSTEM
2' 6
DATE .�,.
SYSTEM OWNER &z ADDRESS SYSTEM LOCATION
(example: house)
exam e: e t
front o
..
w
DA'L'E OF PUMPING UANTITY 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 LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: