HomeMy WebLinkAboutSeptic Pumping Slip - 125 SAW MILL ROAD 3/25/2016 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
M
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, Left i ht rear of h s. , Left/right side of house, Left/
Right side of building, Left/Right front of building, e /Right rear of building, Under deck
Address FL A)
Cityfrown State Zip Code
2. System Owner. � `U
Name
Address(if different from location)
Citylrown State � ¢bC�od �
Telephone Number Q
B. Pumping Record �t
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system. ❑ Cesspool(s) geteptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' 6. Con itioon of System:
c,C �..�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Location where contents were disposed:
('a S. Lowell Waste Water
i
SignAtufe 9t Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
- o
System Pumping r l
Form 4
DEP has provided this form for use by local Boards of Health. M1�� � � " he
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 houspL
,Pafof h6-- , 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)
Cit /Town State Zip Code
Telep one Number
B. Pumping ecord
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 ® o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition o System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
L.S.D. LqWell Wastp Watpr
Signatur " ler Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth Of Massachusetts
City/Town of
Pumping r t
Form 4
'{'AAI SV 04`4
DEP has provided this form for use by local Boards of Health. Other form a e used but e
information must be substantially the same as that provided here. Before your
local Board of Health t4 determine the form they use. The System Pumpi d to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side_of ho-use, Right side of house, Left front of house, Right front of house,
Left rear of ho ight rear of hots Left rear of building. Right rear of building.
Address ��:._ . ,=t:�4..t,�,� ' �� �'�..t�".a-✓� `��""�..,r,..__�� .. ��.,�.w;�__.
City/Town State Zip Code
2. System Owner:
------------------------- --------
-
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
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. Conditio of yst -n:
KI V
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc _
Company
7. Loca zorrwhere contents were disposed:
G.L.S.D Lo ell ste Water
Signature c) uleL Date
t5form4.doc•06/03 System Pumping Record,Page 1 of 1
Commonwealth ®f Massachusetts
City/Town of ��
System Pumping Record ?OV
l"
Form 4
DEP has provided this form for use by local Boards of Heal!,. �0 ttk
Information must be substantially the same as that provided IYere.'I lu ore" s but the
...or fot
I�etiare 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: Left front, left rear, left side of house. Right fror�t right rear-right side of house.
forms on the
computer, use
only the tab key Address
to move your
cursor-do note ----- —
use the return City/Town State Zip Code
key. 2. System Owner:
`w -
__._ Name
Address(if different from location)
City/Town State Zip Code
& IS _-
Telephone Number
B. Pumping ecord
1. Date of Pumping Date �G � 2. Quantity Pumped:
Date Gallons
3. Type of system: Cesspool(s) Septic Tank [j Tight Tank
Other(describe): —
4. Effluent Tee Filter present? Yes /No If yes, was it cleaned? p Yes No
5. Condition of System: vv�rz �Al
6. System Pumped By:
Neil Bateson _ F 5821
Name Vehicle License Number
Bateson Enterprises Inc _
Company
7. Location where contents were disposed:
:L.S.D Lowell Waste Water
igna ure of H Or Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
f
TOWN OF
SYSTEM PUMPING RECORI),
r
DATE:
SYS'T'EM OWNER& AIDID RE SS SYS'T'EM LOCATION
m use)
(example:tee �front o a .... ..
a
DATE OF PUMPING: � � !...P QUANTITY PUMPE ID d r__ GALLONS
CESSPOOL: NO ... w, S SEPTIC TANK: NO YES
NATURE, OF SERVICE: ROUTINE, EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE,R
HEAVY GREASE BAFFLES 1 PLACE
FOOTS LEAC + ELID RUNBACK
EXCE SSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(E LA
SYSTEM PUMPE ID BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D A__. Lower Waste_
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 5
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: - ' f �—Z QUANTITY PUMPED /S -- 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:
Commorrwefrltlr ot`11 asslichusetts
�ywt+�ror �,ttivorer Systerr� t_,c�ctrtiorr
oc
Mm
1)frte of 'rr cur g; Pumped:..... �. , uaitit 2^
rllors
Cesspool: No ���� Ves Septic 1'ank: No Yes
Systerrr Purrrped by: el(ei m e ° " License #
Contents trarrsl`errrecl to : r�r fl r-Lawrenc _ r tt f WrB
Date: Inspector
t ,
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Massachusetts
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