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HomeMy WebLinkAboutSeptic Pumping Slip - 130 HAY MEADOW ROAD 4/1/2016 Commonwealth oaf Massachusetts t „ City/Town Of System poi cord Form 4 Des}�'Iflu � f�l.4 diet DEP has provided this form for use by local Boards of Health Irlfp lrYtij 'eseJ, but the information must be substantially the same as that provided rte:° �f °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 u E rrt u fil ig S f house,Left ear of ho�E right rear of house, left side of building, right rear building, under d ck �.. .. ❑:`.J ❑ ... '4 4cJ- CityTrown State Zip Code 2. System Owner: Name Address(if different from location) ------- ---- City/Town State (it PQde Telephone Number B. Pumping ecor V -- 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) ❑'�eptic Tank ❑ Tight Tank ❑ Other(describe): — - - - - -- -- 4. Effluent Tee Filter present? ❑ Yes ©"No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditiort of System: 6, System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location wh re contents were disposed: i G.L.S.D. ,L well Wa a r Signat e f Vauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth Of Massachusetts City/Town of ' e Farm 4 "rO,WN OF NORTH ANDOVER HEALTH P RT'M't N"f" DEP has provided this form for use by local Boards of Health. Other far , 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�rLocation: Left side of house, Right side of house, Left front of house, Right front of house, Y "of hour % Right rear of house. Left rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code ,µ r Telephone Number B. Pumping Record - 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 of System: C, Ak-6�A 6. System Pumped By: Neil Bateson F5821 _ Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: .L `D JI Lowell Waste Water _. g to a of Haul r Date t5form4.doc^06/03 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts City/Town of System in Record a Y ;fHf4VUX) i Form 4 .. Q u� l_Tu l u�i Q�.).A..i���°ni i 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 Important: When fining out 1. System Location: Le front, eft ea left si of lious . Right front, right rear, right side of house. forms on the .. C. j computer,use only the tab key Address to move your cursor-do not City/Town St� Zip Code use the return key. 2. System Owner: Name ! - _ Address(if different from location) City/Town Stat Zip Vde Telephone Number B. Pumping ecor r. m _w_. 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: Q Cesspool(s) .[J`99 ptic Tank D Tight Tank Other(describe): 4. Effluent Tee Filter present? [Q Yes [j.-Nb If yes, was it cleaned? El Yes 0 No 5. Condition of System: / y 6. System Pumped By: Neil Bateson _ F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loc t on..where contents were disposed: L.S.D� Lowell Waste Water , igna ure of H u rr Date t5form4.doca 06/03 System Pumping Record•Page 1 of 1 Commonwealth cf Massachusetts f ,- 00.1O r10 ]" Form 4 nAi A P riM ai lug \ 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 ms o filling out on y �� � p 1. System Location: computer, use '' only the tab key Address - -� _ ___d_._ to move your cursor-do not City/Town State Zip Code use the return key. � 2. System Owner: Name �nm Address(if different from location) y Stator Zip Code City/Town frown �. � � Telephone Number B. Pumping Record Ll Y, 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Q"S ptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes .w.. If yes, was it cleaned? ❑ Yes ❑ No 5. Condition f System: 6. Syste ,Pumped By w Name - - Vehicle License Number Company 7. Location w er contents We r posed: Signature H I Date t5forrn4.doc•06/03 System Pumping Record m Page 1 of 1 RECEIVED ��x Commonwealth of Massachusetts City/f own Of I ~� Syst u in r �q u{K y N Y'1E.. iH p 1q���VW ErForm 0VVr l V G ..�a n DEP has provided this form for use by local Boards of 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 ocation',„� .{� � � M computer, se �_. only the tab key Address to move your cursor-do not -- - – use the return Cityfrown state' Zip Code key. 2, System Owner: Name ---...—_ — Address(if different from location) City/Town Skate Z' Co Telephone Number 13. Pumping Record ` l 1. Date of Pumping gate - - - 2. Quantity Pumped: — - Gallons 3. Type of system: ❑ Cesspool(s) Q--Sepkic Tank ❑ Tight,Tank ❑ Other(describe): ------ - 4. Effluent Tee Filter present? ❑ Yes ❑°" o--- If yes, was it cleaned? ❑ Yes ❑ No 5. Conditioli of System'. 6. System Pu rid By F M,; ce ( ro. - — - ---- Name 5 Vehicle:License Number Company . — ---- – - 7. Location w e ��' ntents dpo d-.-..., . u Signature of Hauler Date _-- — http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 TOWN OF SYSTEM PUMPING RECO" DATE;_ SYSTEM OWNER & ADDRESS SYSTEM LOCATION ,ry (example: left front of house) j- o , DATE OF PUMPING l` QUANTITY PUMPED e I�0() GALLONS CESSPOOL: NO YES SEPTIC TA NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GG®I)CONDITION FULL TO COVED HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVE R OTHER(EXPLAIN) SYSTEM PUMPE D BY: Bateson Enterprises, Inca CG +NTS: CONTE' TS TRANSFERSED TO: .L. Lowell ate