HomeMy WebLinkAboutSeptic Pumping Slip - 212 HAY MEADOW ROAD 3/31/2016 -- Commonwealth of Massachusett-
LTOVV�N�COIFF"l
City/Town of
f Pumping f 01 J
Fora 4 -
y)
NCORIH ANDOVER
DEP has provided this form for use by local Boards o i;`tT Nt, a used, but 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. s,tecation: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of hr us Right rear of house. Left rear of building. Right rear of building.
Address - ---
i
- —�
CitylTown — — - -- _
State-- — --- Zip Code - -
2. System Owner:
Name ------- --- ---- --
Address(if different from location) — - -- — —
City/Town
------- ---------
St Zip Code
Cf 6f7
Telephone Number
B. Pumping Record r
1. Date of Pumping --- - -- 2. Quantity Pumped: --— - -- ----
Date Gallons
3. Type of system: ❑ Cesspool(s) B Septi Tank ank ❑ Tight Tank
❑ Other(describe); --- — — ---- ---
4. Effluent Tee Filter resent?
p ❑ Yes o If yes, was it cleaned? El Yes ❑ No
5. Condit' no System:
V\, wig
6. System Pumped By:
Neil Bateson_ - ___ ______ ___ F5821
Name Vehicle License Number
Bateson_ Enterprises Inc —
Company --
7. Location w e contents were disposed:
G1, D Low to Water
—
- ------ ----
-------- ---
-- --
Signature IF H I Date -
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth Of Massachusetts .
of /Town Of
System o
3< Form
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. Syst m Loca '9n: - /, ,
forms on the �0_ �.. a . l/ ,
computer, use
only the tab key Address F
to move our _.. G" t ✓ 1 �✓ A- 4 ,y ..
y , :.k
cursor-do not Cityrrowm Stake Zip Code
use the return
key. 2. System Owner: C).-
VQ Name
gym,» Address(if different from location)
City/Town Stat Zip Ile
r l Yd
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallo(((ns
3. Type of system: ❑ Cesspool(s) f 3"§,,eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Pao If yes, was it cleaned? ❑ Yes ❑ No
5, Condit'o f System:
r✓L/� Cam'' � ✓� . `�
6. System Pum By' '
..
Name ` Vehicle License Number
Company
7. Location ere contents were sp sed:
r�.
Signatur Date
t5form4.doca 06103 System Pumping Record^Page 1 of 1
/f
TOWN 9 "" \
SYSTEM PUMPING E
DATE:-- la �
SYSTEM OWNER &rv..ADDRESS SYSTEM LOCATION
(example- left front of houw, )
/,lr(J6�,k� Ltd( 6-�
DATE OF PUMPING:
s �- ` b X QUANTITY P LIB < GALLONS
CESSPOOL: NO YES ��._. SE IC TANK: NO YES
NATURE OF SER'V'ICE: ROUTINE EME, E1 CY
OBSERVATIONS:
GOOD comrrION � FIJLL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROO'T'S LEACH+1E LIB RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER _ - OTI:II7JIb (EXPLA
ys m PumpE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS ENTS TI SFERRED TO: G.L.S.D.—Z Lowell Waste
i
TOWN OF J-1JAdc-f
SYSTEM PUMP G RE, CO"
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
fic (example: left front of Douse)
'(4 k Q"C 0 '0
- , ow
IDATE®F P Ga QUANTITY PU EID 4 500 GALLONS
CESSPOOL: NO YES SEPTIC TA NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIIDS FLOODED
SOLIDS CARRYOVE R OTHER(E L
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: .L. L w l9 s#e
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 1Q�Q ��
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
ac605
DATE OF PUMPING: QUANTITY PUMPED0 GALLONS
CESSPOOL: NO ZYES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIHIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: 66 t1L �+
COMMENTS:
CONTENTS TRANSFERRED TO:
� � r