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Home My WebLink AboutSeptic Pumping Slip - 72 SAW MILL ROAD 3/21/2016 Commonwealth of Mas'sachusetts u City/Town of System i c c4 y, Form 4 DEP has provided this farm 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, a Right a ra of ouse j Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Ad s A,,i-,Lr City/Town State zip Code 2. System Owner: 11400 Name Address(if different from location) CitylTown ' State -�� Zip Code Telephone Number 1 B. Pumping Record 1. Date of Pumping � � 2. Quarltity Pumped: 030 Date Gallons -R 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes B� 0~ [ No 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. Locatio here contents were disposed: _5a 4LS Lowell W aste Water Sigaule Date t5form4.dac•06/03 System Pumping Record•Page 1 of 1 1 Commonwealth Of Massachusetts f u City/Town of a w° System Pumping Record 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 1. System Location: Left/Right front of house '/Right;fd_-4af„6&sd, 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: m .� q ,r Name Address(if different from location) City/Town Sta i M 1 bode 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? ❑ Yes � If yes, was it cleaned? ❑ Yes ❑ No 5. Condit` Qf System: ,� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company , 7. Location: jhere contents were disposed: LL S. l y Lowell Waste Water Sign to a Haule Date t5form4,doc•06/03 System Pumping Record.Page 1 of 1 IL S Commonwealth of Mssachuett City/Town of RECEI System Pumping RC r Form 4 () aq 01r.NORTH TuDOTr HEALI.H DEPARTMENT DEP has provided this form for use by local Boards of "Miff —er f6R� i y 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 front of house; right front of house, left side of house, right side of housg,-L'ft rear of house fjght rear of house, left side of building, right rear of building, under deck. CityTTown 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: C Date Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Other(describe): — -- - --— — 4. Effluent Tee Filter present? ❑ Yes ❑-tdo J~ If yes, was it cleaned? ❑ Yes ❑ No 5. Conditiop of stem: (� 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location-Wh- re contents were disposed: LD Lgvyell Aste Wat Signature o; au ,r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of assac usetts City/Town of a System Pumping Recor N 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use V` only the tab key Address II to move your N �Y�(�0�cl /'� Ct� C) cursor-do not City/Town State Zip Code use the return key. 2. System Owner: C)C)(Q- e L6, PnaI TO Name Address(if different from location) City/Town State 3^ �,i�C;de Telephone Number Oy t B. Pumping Record i h 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [9ZSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter pr fro If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Systeq:reatMent Plan i nswi fit, MA 0193-8 6. System Pumped By: Name r 1 Vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc-03/06' System Pumping Record•Page 1 of 1 Commomwea0h of Akmadm"w"I'SS l pttumS;maae;Fruaryrmat°ts w NO 16 t ( � l TOWN OF N _rH ANDOVER HEALTH DEPARTMEN-r �w �ww�w � �PoPo�wwW �w� �mmmw�wwmWAW�ww � m�� rrt, MM T p ,z E " ttoratpu CSoo a Septic �a ............ r Cote of mmpapvd et �� „�� @' jonflty Pumped: �r ,rJ �� aallr�rr� Sys&sumwum hunped Byu Wild Ia r '", Permit Com iontsim ironsferved to: „ itchbUrg Caroa°utent,m Etasposed ot° Plant bat Pump”. 0 Coarm*Horum of 15ystem/00we Comments bep Approved Form - 12/07/95 t FORM 4-SYSTEM PUMPING RECORD CURRIER SEPTIC SEPTIC & DRM: SERVICE 107 FOREST STREET;MIDDLETON,MA 01949 (978) 774-2772 CO MONWEALTH OF MASSACHUSETTS !i7 C)�✓4' ✓ ,MASSACHUSETTS SYSTEMPZIM. INN RECORD SYSTEM OWNS : ;1 ` t1 SYSTEM LOCATION: V- r� 1 1 GY f" > '� rA 15 I�r � ec DATE OF PUMPING: (�( / QUANTITY PUMPED: / GALLONS CESSPOOL: NO YES SEPTIC TAMS: NO YES SYSTEM PUMPED BY: CURRIER SEP'T'IC & DRAIN SERVICE CONTENTS TRANSFERRED TO: 9 1,12 (/ y C� DATE: G?I INSPECTOR.