HomeMy WebLinkAboutSeptic Pumping Slip - 75 HAY MEADOW ROAD 4/1/2016 i
Commonwealth
City/Town
YS
Form
,Wm .
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/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 6
PC
City/Town state Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stat ���gmmyyy gam.}\( Zip ppy6 e / p y
Telep one Number N
- t
B. Pumping Record
1. Cate of Pumping Date 2. Quantity Pumped: Gallons
. Type of system: Cesspool(s) ErSeptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? ED Yes Ej No
5. Condition of sy tern: Q
PCC Vr„
6; System Pumped 6y:
Neil Bateson F5321
Name Vehicle License{Number
6ateson Enterprises Inc'
Company
7.4igne' ere contents were disposed:
Lowell Waste Water
liule Cate
t5forrn4.docm 06103 System Pumping Record m rage 1 of 1
Commonwealth Of Massachusetts
u City/Town of
Pumping System r jI ' ke
Form 4 1OWN OF-
H[f! �d FHS.>Ei°+�
DEP has provided this form for use by local Boards of Health. Other arm '"ffi ° i ii;od'm tt th
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 e iAig fjf ont of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ Right fron of building, Left/Right rear of building, Under deck
Address �c, '�, -% _ C:'-�'....�.�1 j'��C✓,�"c_,C �,� ,,.�,�, r�, i
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown Stat 6 , Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons A;
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. Conditkon 9f System:
JU0 f- Ne q U�0,1 i C�s t"�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company .
7. Locatio here contents were disposed:
C�L'S. Lowell Waste Water
( f3
Sign toe I HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
RECEIVED'RE
u City/Town Of
a
System Pumping Record
Fora 4 T A N NORTH ANDOVER
t4 AI TH DEPAi�"t°�MENT
DEP has provided this form for use by local Boards of Health. Other a use , uf" ie
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the farm 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 Ping,I Rig ront of hous Left/Right rear of house, Left/right side of house, Left/
i ht side of buil Left/vht front of building, Left/Right rear of building, Under deck
R g g
Address ¢ � 0
City/Town "C < State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State p Code
Ted one Number
B. Pumping Record
e'. I(' p �
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Sep It c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a N If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi 9 System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wljereontents were disposed:
4&gntub Lowell Waste Water
Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
a System Pumping car
Form 4
nx,
DEP has provided this form for use by local Boards of Health. Oth rfoWWAOI W4 e
information must be substantially the same as that provided here. of I k 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 hou� Left front of house,)Right front of house,
Left rear of house, Right rear of house. Left rear of building. Rlgh`t rear of building.
--------- -------
Address
City/Town State Zip Code
2. System Owner:
Name — ----_.. ----------—
Address(if different from location)
-------- - -----------
------------ ---
Cityaown
State .:,� ` Code
.
Telephone Number
B. Pumping ecor � ;:_
1. Date of Pumping -- -- -- 2. Quantity Pumped: Gallons
3. -----.
Date
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe): – -— — —
4. Effluent Tee Filter present? ❑ Yes ®'Jo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0-
6. System Pumped By:
Neil Batesan __ ___ __ F5821
Name – Vehicle License Number
_Batesan Enterprises
Company
7. Location where•contents were disposed:
S.D� / Lo II aste Water
-- ----- -----
Signatur of a er Date
t5form4,doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Ith of Massachusetts
City/Town of
System Pumping Record �
Form 4
�w
DEP has provided this form for use by local Boards of Health. Oth�� for'�i`�imayb6`t�s`ed'"bUt e
information must be substantially the same as that provided here. efore.,ustng t�lS fore �.�he 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 rear of house, Right rear of house. Left rear of building` hTF( h,.f_b Right front of house,
y g ft front o ata
ar o building.
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State �, Zip Code
Telephone Number
B. Pumping ec rd
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-"Septic Tank ❑ Tight Tank
❑ Other(describe): - - - —
4. Effluent Tee Filter present? ❑ Yes [ °1Vo If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System: tt
Lw
6. System Pumped By:
Neil Bateson F5821
--- --._.- ----------------- ---—
Name Vehicle License Number
Bateson Enterprises Inc
---- --------
Company
7. Location where contents were disposed:
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Of MassachUsetts
City/Town O ar ,� ii7
° System Pumping
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 h y u
local Board of Health to determine the form they use. "The System Pumping Record must be submi to
the local Board of Health or other approving authority.
A. Facility information
Important:
When tilling out 1, system Location-
forms on the
computer,use -- ----- —
only the tab key Address
to move your ~ -L '" _—_----
cursor-do not Crky/Tawn State Zip Code
use the return
key. 2, System Owner:
-------- ----------------------- --
Name
Address(if different from location)
-- Zi Code
City own State rw " p
Telephone Number —
B. Pumping r
- 2, Quantity Pumped: ll
1. Date of Pumping -r�at� - Y Gallons
3. Type of system: ❑ Cesspool(s) ❑`8-6ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes U-No If yes, was it cleaned? ❑ Yes ❑ No
5, Condition of System:
6. System Pumped By _..
y ..
Name Vehicle License Number
---
Company
7, Locatio, here contents w re isposed:
Signatu of ler — Date ---- ------
t5form4.doc•06/03 System Pumping Record m Page 1 of 1
Commonwealth Of Massachusetts
City/Town of
i
System Pumping Record
it
Form 4
1
DEP has provided this form for use by local Boards ajf Health: 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 Loc tlon:
ti
computer, use _
forms on the
/ l
p mm
only the tab key Address
cursor-do not _
- - -
to move your
Cit /Town -- _.—----
use the rekurn y Stake Zip Code
key. ,w
2. System Owner:
Address(i(different from location) -----" — -- --
City/Town State p n- —
Tele b6'ne Numb de
o
er -
B. Pumping record ,.,.
f� ~ -
1. Date of Pumping Date 2. Quankity Pumped: -------
Gallons
3. Type of system: Q Cesspool(s) Q Septic Tank ❑ TightTank
❑ Other(describe): -- --- ---- --- —
4. Effluent Tee Filter present? ❑ Yes ❑-1Vo If yes, was it cleaned? E] Yes ❑ No
5. Conditi of S��stem:
6. c
Systeq1 Pumped ed By
Name Vehicle License Number
Company
7. Locatio ere content ere o
Signat e o ler Date --_
http://www.mass.go ep/ ater/approvals/t5form s.htm#inspect
t5form4.doc•08/03 System Pumping Record•Page 1 of 1
N � , I
TOWN OF
SYSTEM PUMPING RECO
DATE:"� .
y
AJ D1 1�%:dR
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(examples left front of Donee)
0 e
DATE OF PU ING: tYES QL ITY PU EID : GALLONS
CESSPOOL. NOD SEPTIC TANK: NO YES
NATURE Or SERVICE: IzOt1T EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
FOOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS _ _ FLOODED
SOLIDS CARRYOVE I2 OTHER(EXPLAIN)
SYSTEM PUMPE ID BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: .Lo o Lowell Waste
1� t� ..c,
TOWN OF
SYSTEM PUMPING RE CO"
DATE:
SYSTEM OWN DD RE SS SYSTEM LOCATION
(example: left front of house)
. } J
_ ..
DATE OF PUMPING: 4..r .. QUANTITY TY P PEID : I �; C� GALLONS
CESSPOOL: N® --- YES SEPTIC TANK: NO YES
NATURE OF SERVICE. ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE' R
MEAN GREASE BAFFLES IN PLACE ROOTS LEAC14MELD RUNBACK
EXCESSIVE SOLIDS FLOODED -
SOLIDS CARRYOVE R OT HE IR(E L
SYSTEM PUMPED BY. Bateson Enterprises, Inc.
COMMENTS:
CONN'TE,N'TS TRANSFE RRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example:p t front of house)
d
e
b � `
"
DATE OF PUMPING: +" ' ` QUANTITY PUMPED ) GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YESd� d"
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'
....,. x
('orrnrrorrw alth of Massachusetts
� stern Location System Ownr 'e y'
c,;° c
Date of I'uurlring: ���� Quantity Pumped: gallons
e,�m�.�
Cesspool.. No ( ves �._� Septic "rank: No (_._) �(es
System Pumped by: elre'date Fob Me4 License #
Contents transterrred to : t�retc r l�travr�nrr�r �5aar Derviatrlct„ _ _ ____ _ _—
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