HomeMy WebLinkAboutSeptic Pumping Slip - 45 HOLLOW TREE LANE 3/17/2016 Commonwealth c u fit
_ City/Town of
YS
Form 4
DEP has provided this form for use�by local Boards of Health. Other forms nay be'used, brit the
information must be substantially the same as that provided here. Before usi6gthis farm, check with your
local Board of Health to determine the form they use.The System Pumpin Racord must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1 R� ht side of buil ne, Left/Ri on of hous , Left/Right rear of house, Left/right side of house, Left/
Right g g ron 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" �j
C ! PI Ap!rode
Telephone Number
B. Pumping Record --
1. Date of Pumping Date 2. Quan. Pumped: .,
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of S stem:
v c
6. System Pumped By:
fy
Neil Bateson F5821 1
Name Vehicle License Number
Bateson Enterprises Inc
Company F JUN
f
7. Location be contents were disposed:
C L S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record a Page 1 of 1
f Commonwealth of Massachusetts
City/Town of � � �' � �VED
System Pumping cr
Form 4
OWN OF M)tR"N+i ARiDOVE� R
DEP has provided this form for use by local Boards of Health. Other forms ma b6 d,Lib1St�hW1��i°�i���
s
information must be substantially the same as that provided here. Before using 1 'GG, 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 front of 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.
f
} t
CitylTown State Zip Code
2. System Owner:
Name
Address(if different from location)
-------------
City/Town State Zip Code
Telephone Number l
B. Pumping ec r
)
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? ❑ Yes ❑-°No If yes, was it cleaned? ❑ Yes ❑ No
5. Condi7n,of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location-Wh re contents were disposed:
G L.S. ..
ste �
�D L_ �I Wa
Signature/of ktaul4r Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1
ICN Commonwealth Ith Of Massachusetts
City/Town of
a System Pumping rd
fi
Form 4
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
Important:
When filling out 1. System Location,,,
forms on the w._.
computer, use — ___ ----- -
f w
�' �� -...- - --
only the tab key Address
.w
to move your
cursor-do not - it /Town �,� i '..•���..,, "��� � ,�_..,,
-- tale Zip Cade
use the return C `
y
key. 2. System Owner:
Q - .
Name -- --- ---------
- -- - -
_ -- - -------- -- - - —---------
Address(if different from location)
-- -- --- ---- --- ---
--- ----- ----
- Zi
City/Town State �' .,� , p Code
Telephone Number
_..
ber
P
B. umping Record
Date p Gallons __....
1. Date of Pumping 2. Quantity Pumped:
3. Type of system: ❑ Cesspool(s) D-186ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes,❑°' o....- If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: __._
J -e
6. ed :
S ste P m B ,„. .� . .
v �, v
A
Name > vehicle License Number
Company — -- -.
ts re?is osed:
7. Lacation w �c�ten p
t - _
Signature of au - Date -
t5form4.doc•06/03 System Pumping Renard^Page 1 of 1
TOWN OF V EIVED
SYSTEM U
DATE: .FOWN OF NOR"UH ANDOVER
HEALTH DEPAUMENT
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example- ..- le front o f house)
J "ewP. ,,,, lg • ,moo+'"' /
DATE OF PUMPING: .,, 6TITY PUMPED GALLONS
m,
CESSPOOL: NO �° YES SEPTIC TANK: NO YES
wr
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:
COMMENTS:
CONTENTS TRANSFERRED TO: .,