HomeMy WebLinkAboutSeptic Pumping Slip - 216 RALEIGH TAVERN LANE 3/9/2016 Commonwealth of Massachuseffs
R r Cityffown oi
n System Pumping Record
.
Form 4
®EP has provided this fora for us&by local Boards of Wealth. 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 Wealth to determine the form they use.The System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
® acility Information
1. system Location Lr�ft.%Ridfrorlt of house Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right-fr6nt-of building, Left/Right rear of building, Under deck
Address �"� G �•�; �,� �_� °`��^ �� ./�...�:�- "v (,�, � �. =�� � �.Q,.� /.
1,
City/Tawn State Zip Cade
2. System Owner:
Name 777
Address(if different from location)
Cityrrown ' Sta � Cade
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Cate mpe Gallons t®�
3. Type of system: Cesspools) Se Tank Tight Tank
Other(describe): �.-- "
4. Effluent Tee Filter present'? Yep �"tUo If yes, was it cleaned? Ej Yes No.
5. Condition oA f S stem:
6. System Pumped By:
Neil Rateson F5821
Name Vehicle License Number
6ateson Enterprises Inc
Company
7. Lo ` -where contents were disposed:
. c' Lowell Waste Water
Sign t e Waule ®ate
t5form4.docm 06/03 System Pumping Record a Page t of 1
Commonwealth of Massachusetts �f R VEI,
u City/Town of
a
System umpin r ..
Farm 4 �
�C`��fll�ti€11-16(J6a,�l6rG'di�r..�\!i`.W''t
i
DEP has provided this form for use by local Boards of Health. Other fo ms�ma� add,'bud tie
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/d{gf. -of ,.-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
�a
2. System Owner:
(A
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record �
Cl
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) [S' Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes c 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. Location-where contents were disposed:
G�ml_S. Lowell Waste Water
-f-Y1AA. I-() ,
Sign toe I Haule Date
t5form4.doc•06103 System Pumping Record.Page 1 of 1
Commonwealth ®f Massachusetts RECUIwED
City/Town Of Z0 1Z
System in g Record 4
Fora 4 TOM,!aY�ic)F i1/Eir,iN)VED1
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 side of house, Right side of house, Left front of house front ofr
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address .-_.,
City/Town State Zip Code
2. System Owner: -0
Name J
Address(if different from location)
City[Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping lo -jq �2uantity Pumped: 0
Date 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: P
A'C � /f
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locaton-where contents were disposed:
__L .D,, Lowell Waste Water
*r. "&J4
Igrpture of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
a
System Pumping ecor
Fora 4 IQ '
DEP has provided this form for use by local Boards of Health t be used ut the
information must be substantially the same as that provided he a tie vri � i{� i iii, heck with your
local Board of Health to determine the form they use. The System-P rnpi Recur e submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:d�ft.PRight rant jeft/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
r
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State '" _. Zip Cede
Telephone Number
B. Pumping Record
I
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? w -.,...
p El ® No If yes, was it cleaned? [I Yes ❑ No
5. Conditio?C�04 ystem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where,contents were disposed:
'G. Lowell Waste Water
Sign toe I Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
---- —
Commonwealth of Massachusetts
_ City/Town of
a
System u pin Record
Form 4 (1
M
DEP has provided this form for use by local Boards of Health. , but the
information must be substantially the same as that provided h i " 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 house, Left front of h use Right front of hous"m e
;,
Left rear of house, Right rear of house. Left rear of building. Right rear of bultri"ng:� '° m "
Address Cl•
City/Town ( State Zip Code
2. System Owner:
-- ------- _- ---
-c
Name
Address(if different from location)
Cit /Town —— St(t&, o�
y a "t r I C
Telephone Number
B. Pumping ec®rd -
. .. ..
=-- .
1. Date of Pumping - �` " 2. Quantity Pumped: -- ----
Date Gallons
3. Type of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe): --- -- —
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�
..ANC .5 _w
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-,where contents were disposed:
L ell Waste Water
Signatur of a er Date
t5form4.doc•06/03 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts „ .. ...
M
City/Town of
x` System Pumping Record
Form 4 ,AJ 3
in provided a Boards
%uuI u s ed�p t
h
o hs fom, �he ck
with your forrmationmst be substantially the sameasthat provided here. B re usi
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 Location: Left front, left rear, left side of hou . Rlght fro right rear, right sid of housej
forms on the -
computer, use _
only the tab key Address
to move your <. �-
cursor-do not —
use the return City/Town State Zip Code
key. 2 System Owner: t
3 Name
Address(if different from location)
City(rown Std Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: 0 Cesspool(s) eptic Tank Tight Tank
Other(describe): ,.�'�
4. Effluent Tee Filter present? Ll Yes 0•- If yes, was it cleaned? Yes No
5. Condition of S stem:
_._ ( .,,/�,✓`t-.z'A/ 1`
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio Mere contents were disposed:
L.S.D Lowell Waste Water
M-0
igna ure of H Or Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts . . ... . . . .................
.�o
I r City/T'own of
System Farm 4 Pumping RecRecord ?"'M
OWN q pry q yip yq[ g'�
t�III° N O NORM I H F�M,")QVIIEIR
be
DEP has submitted d to the local Board for use
of Idea th or atherapprav approving tk�o'rt y: errii Pialr
pthltg: eco d mint
A. Facility Information
Important:
When filling out 1. System Location:
forms on the r�
computer, use (40 I .elk,/"Oi._q� . gip... r� Y)
only the tab key Address
to move your (I(-\86 e ; f✓�`��/� 0
cursor-do not City/Town State Zip Code
use the return
key.
2. System Owner:
�!
r'
tab
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �0 � � (� 2. Quantity Pumped: /. ... a
Date Gallons
3. Type of system: ❑ Cesspool(s) 0)Septic Tank ❑ Tight Tank
❑ Other(describe): ----- ----
4. Effluent Tee Filter present? ❑ Yes Ef No If yes, was it cleaned? ❑ Yes ❑ Na
5, Condition of System:
6. System Pumped By:
so-)j _
Name Vehicle License Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
= a �
� (y, c
DATE OF PUMPING:P >> QUANTITY PUMPED (ao e GALLONS
CESSPOOL: NO � YES SEPTIC TANK: NO YES A,
NATURE OF SERVICE: ROUTINE _, EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: � ��
COMMENTS:
CONTENTS TRANSFERRED TO: '
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD 0
IDATE: -'
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
cjA
DATE OF PUMPING: _�_� a� QUANTITY PUMPED � GALLONS
CESSPOOL: TACO ""YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE � � EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHF,IELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER, OTHER (EXPLAIN)
SYSTEM PUMPED BY: -�
COMMENTS:
CONTENTS TRANSFERRED TG: