HomeMy WebLinkAboutSeptic Pumping Slip - 63 HAY MEADOW ROAD 3/31/2016 Commonwealth of Massachusetts � vvrj
City/Town of NOK1,6 /+a"
System Pumping Record
Facility Information:
System Location:
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Address i
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City/Town State Zip Code
System Owner:
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Name:
Adress (if different from location of pump)
City/Town State Zip Code
Telephone Number
Pumping Record
Date of Pumping- Quantity Pumped If tf gallons
Type of System____X Septic Tank Grease Trap Other (what)
System Pumped by:
Company: ROOTER-MAN 46 Portland Street Lawrence, MA 01843
Location where contents were disposed:
Signature of Hauler Date `�
Commonwealth Of Massachusetts
City/Town of ?013
0
Pumping r N°k��,'W1 J OF
Form 4 HEALIII DEPAF,1,740 i ul
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 forrn they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System building,y,.
Ri hr oih o
e Left/Right rear of house, Left/right side of house, Left
Rg ht side of Left RI g�p nbuilding, /
Left/Right rear of building, Under deck
Address .,
City/Town State Zip Code
2. System Owner:
,,l° r ' w
Name
Address(if different from location)
City/Town
tats
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank
❑ Other(describe):
resent? Yes❑ ❑.New...,._
4. Effluent Tee Filter p �--wrr
If yes, was it cleaned? El Yes ❑ No
5. Condition of tem.
r
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company ,
7. Location where contents were disposed:
L S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06103 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
it y/Town ®f
ystem Pumping Record
Form 4
�q
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 of front, ft rear, left Sid f hour Right front, right rear, right side of house.
forms on the _
computer, use
only the tab key Address
to
--- --
ko move your �..� � .:.�.�..�
cursor-do not City/Town!town
use the return tY State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
City/Town Stat Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: 0 Cesspool(s) Ej-yep ltlt c Tank Tight Tank
E Other(describe):
4. Effluent Tee Filter present? [j Yes 2N If yes, was it cleaned? Yes No
5. Condition of System:
V , \
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Anau 4Hu Lowell Waste Water
Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of I
System Pumping Record
Form 4
I'4
DEP has provided this form for use by local Boards of He Ift The$ysttem i umpiiig 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 f'
computer, use
only the tab key Address
----------
to move your _.�.
cursor-do not
use the,return CitylTawn (".'y
Stake Zip Code
key. 2. System Owner; /
IIJ
Name --- ---- -
rtem ----- -- --
Address(if different from location)
City/Town State, y _ Zip Code
Telephone Number -- - --- —
B. Pumping Record
1. Date.of Pumping at -- 2. Quantity Pumped: - -- ----
Gallons
3. Type of system: ❑ Cesspaal(s) aoptic Tank- ❑ Tight Tank
❑ Other(describe): - —---- --------_---
4. Effluent Tee Filter present? ❑ Yes ❑N If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System } ) ( "
��+�.....4 '"p �'... ,.,.'.;� t...f..,.. 1 '..�...✓
6. Sys m PgTped By
,
Name �" — - -- ---- ---
_. Vehicle License Number -----
Company _ --- -- -- -
.7. Location where contents were disposed:
I
C -
Sign tur of H Winer - Date -
http://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
t5form4.doc^06/03 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM E
PUMPING X0
DAT TOWN()F t,g:)pjH ANDOVER
HEKT� DE
SYSTEM OWNER & ADDRESS SYSTEM D,OCATION
(example: t front of house)
: m lo. left
rc'
A,,�°
DATE OF PUMPING: GALLONS
CESSPOOL: NO YES SE DC TA d NO -- - - YES
NATURE, OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOODS CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
FOOTS LEACHFIELD RUNBACK
EXCESSIVE SOL S FLOODED
SOLIDS CARRYOVE R OTHER R(EXPLADN)
SYSTE M PUMPE DD Y: Bateson Enterprises, Inc.
COMMENTS:
So
C0NTri,NTS r wru ,D T09 GIAD L-�""Lowefl rite
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 13._,Q
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
J4-j I I (example: left front of house)
DATE OF PUMPING: x--13 `C,�QUANTITY PUMPED 'P GALLONS
CESSPOOL: O N d YES SEPTIC TANK: NO YES --v/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: U Co .
COMMENTS:
CONTENTS TRANSFERRED TO:
CommomVealdi of Massachusetts
Massachusetts
�5YAtelvl Pumping Record
System Location
a,r
Date of Pumping:
Quantity Pumped: gallons
56(/
Cesspool: N o Yes Septic 'I'mik: No Yes
System Pumped by: varedare License/I
Contenishansficitredto : 9rqq ter LqwreiiceLy
Date:
111spec