HomeMy WebLinkAboutSeptic Pumping Slip - 24 PATTON LANE 3/21/2016 Rom Commonwealth of Massachusetts
: City/Town of
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 side of house, Right side of house, Left front of house, Right front of house,
Left rear of house, Right rear of ho se.
Addross
CltylTown Stafe Zlp Code
2, System Owner:
Name
Address(if different from iocaiton)
Cily/Town Stafe zip Code
c -` -33
Telephone Number
13. 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 f=ilter present? ❑ Yes 9-7q0 if yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System:
B. System Pumped By:
Nell Bateson
Name
13afeson Enterprises Inc Vehicle License Number F5821
company
7. eLocatlion re contents w ere disposed:
Lowell Waste Wa#er
bate
t5form4•doc•06/03
system Pumping Record•page 1 of 1
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.A;.Facillty Information ..
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.; '. :< t
System Pumpin9 Record r Page S of t
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City/Town of, NORTH ANDOVE g
.'� System Pumping Record
r Form 4
DEP has provided this form for use by local Boards of Wealth. The System Pumping Record must
be submitted to the local Board of Wealth or other approving authorit r•; �.. u
A. Facility Information
Important: MA I
When filling out 1. System Location:
forms on the i OVVPl "iol; i h-�
computer, use
only the tab key Address
to move your .. �"Lt�L,7✓CE � 1�� .. _
cursor-do not City/Town State Zi Code
use the return P
key. 2. System Owner:
Name ---
Address(if different from location)
CitylTown State
Zip Code
Telephone Number
Pumping Record
CB.
Date of Pumping pate
2. Quantity Pumped; Gallons µry
3. ype of system: ❑ Cesspool(s) „„ Septic Tank ❑ Tight Tank
❑ Other(describe): — —
"
2 5.4. Effluent Tee Filter present? ❑ Yes I° -No If yes, was it cleaned? r-1 Yes ❑ No
Condition of System:
6. System Pumped By:�
c w
Name 5 Vehicle License Number
� a. / � /err / 0Y -//
Company
7. Location where contents were disposed:
< � � =
�.-.
0
a f t e date
htt ://www.mass. ov/dep/wat a p rovals/t5forms.htm#ins ect
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k5fom74.doc-06103 System Pumping Record -Page 1 of 1
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE 2 ., , .
SYST EM OWNER&ADDRESS SYSTEM LOCATION
c,)-
DATE OF PUMPING �
. e QUANTITY PUMPED
CESSPOOL NO YES SEPTIC TANK NO YES L5
NATURE OF SERVICE: ROUTINE t✓ EMERGENCY
OBSERVATIONS:
GOOD CONDITION V1 FULL,TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY
COMMENTS:
j
CONTENTS TRANSFERRED TO f ,
SYSTEM PUMPING P-�COE-D
STTEM OWNER & ADDRESS SYSTEM LOCATION
�•�n �� .. .y., r.��- xamPle; Iefl front ofhou �a�� �`��
U.\'I,c OF PUm?INC,L. °, .. QUANTITY PUMPC. D (" C',� LLUv�
C. )S1'OOL: NO YES SEPTIC' TANK: NO YES
`\ ATURE OFSERVICE: ROUTINE EMERCENCY
GOOD CONDITION. '` GULL TO COVER
HEAVY CREASE RAFFLES IN IlLACb'
ROOTS LEACHFIELD RUNBACK..
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER p HF,R (EXPLA.IN)
PNTS:
!'I ANSrEItRED TO:
TOWN OF NORTH ANDOVER
SYSTEM C
DATE: � m
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
s" (example: left front of house)
W eM
w � //v
. F
DATE OF PUMPING: �> QUANTITY PUMPED �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:
COMMENTS:
CONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: ws,
SYSTEM OWNER& ADDRESS SYSTE LOCATION
(example: left front of house)
M -
i 4,rA 1.ci
,ATE OF PUMPING: QUANTITY PUMPED t�
GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
I
NATURE SER CE: ROUTINE
EMERGENCY
OBSER VA►TI NSa
GOOD CONDITION
EA GREASE FULL TO COVER .
ROOTS EAFFLS IN PLACE
LEAC
EXCESSIVE SOLIDS IELD RUNBACK
• FL
SOLIDS CARRYOVER FLOODED
OTHER (EXPLAIN)
' 'SYSTEM
r
1 I
COMMENTS:, /
1
I
f (
TENTS n
,
TRANSFERRED TO:
i
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979-372-7471
MCNTH or
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y L assay ltusctts
System Owner _ System location
Date of Pumping: C'� turtlrtity Pumped: gallons
Cesspool: No Yes Septic 'i'ettk: No
Yes
System Pumped by: 974eejoa 'fe license#
Contents transrerrred to : greater wretice ganl gty Ols-trtct
Date; _ lttspector:
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