HomeMy WebLinkAboutSeptic Pumping Slip - 67 RALEIGH TAVERN LANE 3/11/2016 Commonwealth of Mas*sachusetts
City/Town of �,E
System Pumping Record 014
Form 4 o
POWN Uu' ANLA:VPP'�
DEP has provided this form for use�by local Boards of Health. Other form ma , kLs; `tf)„
information must be substantially the same as that provided here. Before u°sng.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 hous. , J-�ig side of hous ; Left/
Right side of building, Left/Right front of building, Left/Right rear of uilding, Under earl
Address y, .�/4.'�.� � C'.^C„✓1.�' U� .���� r � �
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' State
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ��k�o -
If yes, was it cleaned? ❑ No
5. Condition f stem:_
LA,4e,-z"-,
6. System Pumped By:
Neil Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio re contents were disposed:
G L Lowell Waste Water
,
SignAtufe 9t Haule Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth Of Massachusetts RECONEU
w City/Town of
a n System Pumping Record
Form 4 ,r,&v�rs�; I a i�a� I I ntii•i� t i:c
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(Le-0 right(�ide ;.Left/
Right side of building, Left/Ri-qht front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
G�yvlG�✓'1 u'�.
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Punning Record
1. Date of Pumping 2. Quantity Pumped: c
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? jYes ❑ No
5. Condition of System: j f
6. System Pumped By:
Neil Bateson F5321
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S� Lowell Waste Water
Sign to a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
a D i lyd //Y�/sf➢ �IY�' /R "wmenxia
., r ' A� !r it %'fi
System Pumping car �,�,�r �
,E
Form 4
DEP has provided this form for use by local Boards of Health. Oth r forms ma t" aut he
N k V 9 r � a� t �,
information must be substantially the same as that provided here.
local �. ia k with your
local Board of Health to determine the form they use. The System urrrptfyg^ftco ttf'"iWt) t°" submitted 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 side of house, right side of house, Left
rear of house, right re_ar of house, left side of building, right rear o uilc�ih , under deck.
City/Town State Zip Code
2. System Owner: �V\
Name - --- -- -
Address(if different from location)
City/Town Stat r Zip Cede
Telephone Number
B. Pumping Record
1. Date of Pumping Date -- 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) []- " eptic Tank ❑ Tight Tank
❑ Other(describe): — --
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ❑""1es ❑ No
5. Conditi n of Syste :
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc. _
Company
7. Lo tllc whe a contents were disposed:
G,L.S.D. oyvlell Wastp Wptpr
Signature a er "" Date
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
lb
-- - it /Town of
- System Pumping Record
w f N O N RTtt ANDOVER A EHEALTi 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 Lacatior Ce e_o"puse;-`Right side of house, Left front of house, Right front of house,
�. dear of building. Right rear of building.
Left rear of house, I h rear of hou
,F�g� n se. Left r.
Address -- ----------
6<J
City/Town State Zip Code
2. System Owner:
Name-- — --- ------------- ---------
------------ -- - --- - --- -- -------------------
Address(if different from location)
--------- ---
-------- ------- --- ---
City/Town State Zip Code
Telephone Number
B. --
Pumping Record
1. Date of Pumping —❑❑(. 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) [NI/Septic Tank ❑ Tight Tank
❑ Other(describe): ---------- ----
4. Effluent Tee Filter present? ❑es ❑ No If yes, was it cleaned? ❑s ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
------- -----
Company - -
7. LoI— i q wFiore contents were disposed:
G.L.S.D,„ Lowell Waste Water
- --
----- ------ ---- --
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
Pumping City/Town of RECEIVED
System rya
Farm 4
DEP has provided this form for use by local Boards of Health. Other for s may
information must be substantially the same as that provided here. Before using " is fof"M ctye&wi 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: Ceft'Wh en filling out 1. System Location: Left front, left rear side of houseight front, right rear, right side of house.
forms on the ' ~�
computer, use
only the tab key Address j ,r , -a"
to move your
cursor-do not Cityrrown State Zip Code
use the return
key. 2. System Owner:
-- H av\
- Name
Address(if different from location) —
City/Town Sta ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: r] Cesspool(s) LJ-Septic Tank Ll Tight Tank
p Other(describe):
4. Effluent Tee Filter present? 0--Y`eDo If yes, was it cleaned? [g--"es [j No
5. Condition of System: ._ C 4-t. ,
r� 'Alvat-6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L. Lowell Waste Water
Date
t 5form4.doc^06/03 System Pumping Record•Page 1 of 1
,w
��® �"'. _..e.
Commonwealth of Massachusetts
City/Town City/Town of
�A�!u N„ N ?e
System
Pumping
Form, - f
i
DEP has provided this forrn 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
When filling out 1. System Location:
K . d
forms on the ' ...
computer, use
only the Y b key Address 1 ..,...... w.. ..i C: .-1, l/\ ! A/411 `z..,c... w`1 p...0, .
to move our
cursor-do not City/Town ` State / Zip Cade
use the return
key. 2. System Owner:
Name —
pan Address(if different from location)
City/Town State , ILI— P�Cocl
Telephone Number
B. Pumping cr
1. Date of Pumping Da-te 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ET Y—e's ❑ No If yes, was it cleaned? ®°°Yes ❑ No
5. Condit' of System:
77-6. S ste
Name Vehicle License Number
.,.. .. _
Company
7. Location w ere contents wer7 osed:
Signat e a er Date
t5form4,doc^06/03 System Pumping Record^Page 1 of 1
. r
Commonwealth of Massachusetts
N. ----- p City/Town Of
System Pumin r
Form 4 ,�
DEP has provided this form for use by local Boards of Health. Other ,
hr's ��nay"b�used, but the
information must be substantially the same as that provided here. Be ere-ustng,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
When oon the
out 1. Syste L�r at rr
Important:
computer,use -- -
only the tab key Address y �.� � �-do not use
cursor-return City/Town State Zi p Code-
key. 2. System Owner:
Name
Address(if different from location)
City/Town Sta ( e
Telephone Number —
B. Pumping ecord
1. Date of Pumping bate - - 2. (quantity Pumped: Gallons —
3. Type of system: ❑ Cesspool(s) ° 6ptic Tank ❑ Tight Tank
❑ Other(describe): ----- - -- - —
4. Effluent Tee Filter present? ( es ❑ No If yes, was it cleaned? ❑°"V es'❑ No
5. Condition �TI)
tem: /
s
6. System P and
Name `
w„ Vehicle License Number
Company
7. Location ere co tents were dis
W
c
l �M
Signature of aL er - Date
t5form4.doc^06/03 System Pumping Record a Page 1 of 1
Commonwealth of Massachusetts
� �.
.a.,.
City/ own of
System Record ������� , 4: `�illl�x
Form 4 }
•v, 1'
DEP has provided this form for use by local Boards of Healthi, T—he 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: r
forms on the
4 computer,use _ ''� ..a_ k .(.,.., ,.
to move your Address q .. _ ,
Y Y tom—
cursor-do not - yh
use the return City/Town State Zip Code
.key. 2. System Owner:
Name . ,.
— — ---- - --------
retli" Address(if different from location)
CityfTown State Zip Code --^
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ®° eptic'Tank ❑ Tight Tank
❑ Other(describe): ---
4. Effluent Tee Filter present? ❑/ es ❑J No If yes, was it cleaned? ❑ `" es ,� No
5. Condition of System:
(,p )
6. Sys Irnpd B
u.
A Vehicle License Number ----
Name
Company ----- -
7. Location w ere contents were disposed:
Signature ul — Date --
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System'.Pumping Record•Page 1 of 1
TOWN OF
r,)
PiMPING RECORD
SYSTEM a ANDOVI
SYSTEM OWNED & ADDRESS ""j SYSTEM LOCATION""'-
. .m,.
(example: left front of house)
-�. ) (-- k J(- uks C,
DATE OF PUMPING: _.4 QUANTITY PUMPED : G
CESSPOOL: NO YES SEPTIC TANK: NO ----- YES
NATURE, OF SERVICE: ROUTINE -- EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVED
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHRE LID RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
r
CONTENTS TRANSFERRED TO: .L® a LowellWaste
TOWN OF
SYSTEM PUMPING
]DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
DATE OF PUMPING: QUANTITY PUMPED : GALLONS
CESSPOOL: NO YE„ d �...,..
S SEPTIC TANK: NO YES `
NATURE OF SERVICE: ROUTINE' EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACLIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OT 'R IE XPLAU9
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS TRANSFERRED TO: G.Le o13 Lowell Waste
TOWN OF
SYSTEM PUMPING RECORD
DATE: �
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: QUANTITY P ED e 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 CARRYOVE R OT HE R(EXPL
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: .Le a Lowell Waste
TOWN OF V,-
SYSTEM PUMPING RECO"
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
'57
DATE OF PUMPING: 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 LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHE R(E XPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
CONTENTS TRANSFERRED TO:
f' I
TOWN OF NORTH ANDOVER
r
SYSTEM PUMPING RECORD M,421'�"�'
DATE: . d
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
6� �-,e'4
6-1
DATE OF PUMPING: -062 QUANTITY PUMPED 1 5 0 0 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: `' ..
�-~� ` n
COMMENTS: 1.... ���- c�4� I°e
CONTENTS TRANSFERRED TO: Cc
- '
Foam 4 System Pumping Record
Commonwealth of Mossachusetss
� Massachusetts
&sj�ei.p bmWn Record
System Owner System Locatio"
I V"J,'Y
MU'v r_"1
9"1 V I
Type: EmeiVlency Routine
Cesspool: No Yes Septic tank: KW 0Yes [3
Late of Pumping: Quantity Pumped: Gallons
System Pumped By: Wind River Environmental, UC Permit#:
Contents transferred to;
Contents Disposed at:
Coate: Pumper Signature:
Condition of System/Oth4r,Comments
Dep Avproved From - U10719.5