HomeMy WebLinkAboutSeptic Pumping Slip - 51 LONG PASTURE ROAD 4/30/2014 Commonwealth f Massachusetts
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oWCI «V� �D,,,�
1 IA Y i`
Form 4
CEP has provided this form for use by local Boards of Health. Other f6i y;rbe irsea,but e
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 h lght front of u4e, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Lem ight front of building, Left!Right rear of building, Under deck
Address r . M
ckj
tm..-
Citylrown ( State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' State ip fade
Telephone Number
B. Pumping Record
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? es ❑ No If yes, was it cleaned? [3-"Ye .,® No,
5. Condition of S stem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiop�where contents were disposed:
aL S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/08 System Pumping Record.Page 1 of 1
Commonwealth Of Massachusetts o... ..
City/Town of
M �
System umpin rd AUG 2 4 ?T0
,a Form 4
DEP has provided this form for use by local Boards of Health. Other � �Sul i Iii wi W`
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&l ig ont of house, mm
Left rear of house, Right rear of house.
Address -
City/Town -'7 State -❑— Zip Code
2, System Owner: Ato
Name — -- -- —
Address(if different from location)
City[Town State r„ ip Code
— U4 - .. � �
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? es No
5. Condition of System: UA—A � MVO ❑
6. System Pumped By:
Neil Bateson
Name Vehicle License Number F5821
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
0 L. .D y Lowell Waste Water
h __C ❑—- bot—��—
Sin ur of Haul r Date
t5form4.doc^06/03 System Pumping Record•Page 1 of 1
commonwealth of Massachusetts
City/Town of
System Pumping Record
of ,
Y
Form
GEP has provided this form for use by local Boards of Health. Oth r fo sr 'r iay be dsed, b'Ot 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 forrn they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important; a
When filling out 1. System Location*.
forms on the
computer, use
only the tab key �� " ... f'
to move your y Address ...f �"
cursor-do not City/town State Zip Cade —
use the return 4
key. 2. System Owner:
Me
VQ -- -
Name -
--- ---- --- --- --- - ----- ---- ----
n Address(if different from location)
- - ------ ----- - --
Cityrrown State y �t ip(,rode
Telephone Number
B. Pumping Record
1. Date of Pumping ®ate - — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0,u eptic Tank ❑ Tight Tank
❑ Other(describe): - --
4. Effluent Tee Filter present? a"`° es ❑ No If yes, was it cleaned? .-Yii ❑
. No
f System:
b. Condition a� m . .6; � �.... �,.
6. Syste Pu pad By � mµ' --— ..
_..
Name Vehicle License Number
Company---"' -- -- --
7. Loca ---
ten re disposed:
Local )w ca._an„
f
Si at e Hauler — Date
t5form4.doc4 06103 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM PUMPING REA
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
b6 IC cz
(example: left front of hoia�
.- (
4.
DATE OF PUMPING: � QUANTITY PUMPE ID : GALLONS
CESSPOOL: NO ''DES SEPTIC TAN K: NO YES
r
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVED
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R ®T +R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENT'S TRANSFERRED TO: .Le a Lowell Waste
TOWN OF C �,.
SYSTEM PUMPING
DATE l
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
k ox
"') ('Jo
coikl
1
DATE OF PUMPING: QUANTITY P ED : j )(� 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 LEACITFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHE R(E L
SYSTEM PUMPED BY: Bateson Enterpnises, Inc.
COMMENTS:
NTS:
CONTENTS TRANSFERRE D TO: 4 �
TOWN OF
SYSTEM PUMPING RECORD
DATE: °b
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
lI (example: left front of house)
( J� 0 ' t�
51 LO'I
DATE OF PUMPING: QUANTITY PUMPED : 1560 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: BateSOrl Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: l J a l