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HomeMy WebLinkAboutSeptic Pumping Slip - 141 MARIAN DRIVE 3/16/2016 Commonwealth of Massachusetts 4 City/Town Of RECEIVED a s System ���p .� �: 2,0 ;; Form 4 C C�''VCV °'R'" iANDOVER DEP has provided this form for use by local Boards of Heal Id, 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 6­7v rear of hoc.us6, Left/right side of house, Left/ Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck Address J C' "" � 7✓ "�:. .., � ✓ ., ti d' City/Town State Zip Code 2. System Owner: Name ^.._.. Address(if different from location) City/Town State ._ Zip Code Telephone Number B. Pumping Record ..._ _. w. 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ❑'peptic . Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Nell Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. LocajiontwtWe contents were disposed: G L S. Lowell Waste Water m, Sign toe I Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts a _ City/Town of X System Pumping Record Form 4 ,, vp, 'MWN OPNORTH ANDOV R HEALTH OEPAR°IWEN- DEP has provided this form for use by local Boards of Health. Other forms maybe use&,,Tut 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 house, ight rear of houLeft rear of building. Right rear of building. Address ------------------ — --- --- City/Town State Zip Code 2. System Owner: Name -------------- Address(if different from location) City/Town State 'p-Code Telephone Number B. Pumping Record � 1. Date of Pumping Date 2. Quantity Pumped. Gallons 3. Type of system: ❑ Cesspool(s) ❑ °Sep°""tic Tank ❑ Tight Tank ❑ Other(describe): ---- ---- - ---- - 4. Effluent Tee Filter present? ❑ Yes KIIo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: P6) /Llt'zlit 1�1 4�__VIUA-4_�_" ------ 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company - 7. Locati r5=wh re contents were disposed: Lowell YVaMp Wate[r-- -- _ Signature of apt r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TON" OF J SYSTEM PUMPING/RFECO ............... DATE:—I--( OCT' 1 9 2004 rovvl,k-)� N-AL I 1 )1 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of Krause) (`C DATE OF PUMPING: q- 1 QUANTITY PUMPE D : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES V/ NATURE, OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVED HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVE R OTHE R(E XPLAIN) SYSTEM PUMPE D BY: tes®n Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste