HomeMy WebLinkAboutSeptic Pumping Slip - 25 SUNSET ROCK ROAD 3/15/2016 City/Town Commonwealth of MassachUsetts
.
o System Pumping Record W14
Form 4 V
T
lEP 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 mint be submitted to
the local Board of Health or other approving authority.
A. Facility
1. System Location: Left/Right front of house, Left/ i Wiear of he s 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
2. System Owner:
Name'
Address(if different from location)
City/Town State Zgx-C d
Telephone Plumber
B. Pumping Record
i
1. Date of Pumping 2. Quantity Pumped:
date Gallons
3. Type of system: Cesspool(s) epiic lank Tight Tank
Other(describe): �.
4. Effluent Tee Filter present? ® 'des o If yes, was it cleaned? E) Yes No:
6. Condition of s m: ,
6. System Pumped By:
Neil Eatesbn F6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locat` n- to re contents were disposed:
Lowell Waste Water
ASignt Houle Clate
t5form4.doc-06/03 System Pumping Record Page 1 of 1
RECXIVED
Commonwealth of Massachusetts
City/Town c
i :�� �quxuisau�i�a ���:��EPAFITMENT
Farm
DEP has provided this formlor 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 houses,+Left/right side of house, Left/
Right side of building, Left/ Right front of building, Left/W@hf-rear-of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping ecor
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 . No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio of ystem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents were disposed:
L S Lowell Waste Water
<:
Sign toe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
LITOWN A
� 2011
in Record F'n A NDOV Form 4 EPARTME
Nf
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-eftJront-Qf house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house; left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name —
Address(if different from location)
--------- --------
City/Town Stale, Zi C d
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? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �� � 1 `✓�
&,�ovo-A-ct,t
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location,where contents were disposed:
L.S �. A i I- ell Waste WAter
Signature 4HO ler Date
t5form4.doc•06/03 System Pumping Record>Page 1 of 1
_�LN Commonwealth of Massachusetts
. a�
City/Town of
System in rcl
Form
DEP has provided this form for use by local Boards of Health. 16irbs�M6y-be t 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 house, Left front of house, Right front of house,
Left rear of hous ig_1®`r'ear"offrousp. Left rear of building. Right rear of building.
Address - - -- - — —
�� ,-
City/Town State Zip Code
2. System Owner: / )
...,i '.
--------- -------
Name --------------------------- -
Address(if different from location)
- -- ---- ---------------
City/Town St Zip Co
... fwd C c �
Telephone Number
B. Pumping Record -- -
1. Date of Pumping - - — 2. Quantity Pumped: _.__----___---
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑°"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? F] Yes 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 when contents were disposed:
L S.D Lowell Waste Water
- ------------
Signature of Hauler D fe
t5form4.doe^06/03 System Pumping Record•Page 1 of 1
Commonwealth f Massachusetts
City/Town of
Pumping System .w..
Form 4 0 9 \I..
i
DEP has provided this form for use by local Boards of Health. Other f i "ma information must be substantially the same as that provided here. Be �� . Z 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:
(.
p
olig t System Location:
f t C
mputer use _.
, 1V.
only the tab key Address a ✓ � lA-zt-A wt omoveyour .��
cursor-do not Cityrrown State Tip Code
use the return
key. 2. System Owner:
VQ Name -— -—
,n Address(if different from location) -- -
City/Town State Zip Code
TelephorteiNumber
B. Pumping Record
e
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑-'S ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ Na
5. Condition of System: / I�
eA
6. Systenru7ped,,p
Name � Vehicle License Number
Company
7. Location wh corrnts r(e di ed:
a
Signature pf Ha er Date
t5form4.docm 06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of I
System Pumping Record
Form 4 "
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
forms filling Important:on tneaut 1, System aca�pn:�a
When filGn
`'j
computer, use _ _ —
— - -—
to move your
only the tab ke y ddres
cursor-do not - -
use the•return City/Town Mate Zip Code ^- -
key. 2. System Owner: . ,
Name — —--- —. -------
Address d different from -
(', location)
Cityrrown Stag — — -
,- � Zip'Code'
Tel ep one 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? ❑ Yes ❑-'No . If yes, was it cleaned? ❑ Yes`❑ No
5. Condition of System:' _
6. Syste P ped By
A #
.w.
Name - - ---
Vehicle�icense Number
P --
Com an Y
7. Locati Mb'e cont'
on ruts wqf 61 s p.osed::
� t+
Signs ure f auler Date ---
http://www.mass.gpv/dep/`water/ppproval8/t5forms.htm#inspect
t5form4.doc•06103
System Punmping Record•Page 1 of 1
RE, CORD RECEIVED
MAY 3 1, 2005
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
� w ._ vS -
oc-
IDATE OF EIJMEINC: ,_ � (` 0 QUANTITY PUMPEID : _ --- GALLONS
CESSPOOL: N ti YES SEPTIC TANK: NO YES---- - --
NATURE OF SERVICE: ROUTINE � - EMERGENCY --
OBSERVATIONS:
GOOD CONDITION - FULL TO COVER --
HEAVY GREASE BAFFLES IN PLACE
FOOTS -- LEACHFIELID RUN-BACK _--
EXCESSIVE SOLIDS _ FLOODED
SOLIDS CARRYOVER -__ OT (EXPLAIN)
SYSTEM PUMPE ID BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell t
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
UC
X
Rock
ac uvv�j""
DATE OF PUMPING:
QUANTITY PUMPED : GALLONS
CESSPOOL: NO YES - SEPTIC TANK: NO YES lz_
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRMOVER OTHE R(E XPLAIN)
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMME NTS:
CONTENTS TRANSFE RRE D TO: