HomeMy WebLinkAboutSeptic Pumping Slip - 224 HAY MEADOW ROAD 4/1/2016 Commonwealth Of Massachusetts
City/Town of
a d S ' tem Pumping r
0EE R II P 4D t l udVi iIf
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 hou , 6eli Ri ti rear of house� Left/right side of house, Left/
Right side of building, Left/Right front of btu( ing, Le /Weight rear of building, Under deck
Address <'
Citylrown State Zip Code
2. System Owner:
Name
Address(if different from location)
cityfrown ' State,. m.(�(-7 47 Z1 Cojlel .. t
Telephone Number
B. Pumping Record
1. Date of Pumping sate 2. Quantity Pumped. 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.
1
" 5. Condition of y tem:
6. System Pumped By:
Neil Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatipn..w,t Qje contents were disposed:
G S. Lowell Waste Water
Q4
c
SignAtufe qj Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
- f City/Town of
System Pumping r
y Farm 4
DEP has provided this form for use by local Boards of Health. Other forms mar be used, but the
information must be substantially the same as that provided here. Before u ing ti is f6rm, ohao with`ybur
local Board of Health to determine the form they use. The System Pumping Pecord must1be submitte to
the local Board of Health or other approving authority. �
Of
A. Facility Information
1 eyar u house trn.htrear ofth of use,left side front
of building, right ea of building, under eck.y h`a
,
City/Town ( State Zip Code
2. System Owner: l mm
7 y
Name - -- —
Address(if different from location)
– --
City/Town State C., w Z'p ..4de ,
Telephone Number
B. Pumping ecord -- ,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑-°'< t Tank
p El Tight Tank
❑ Other(describe): — - - -- _
4. Effluent Tee Filter present? ❑ Yes D~°Na If yes, was it cleaned? ❑ Yes ❑ No
5. Condit'p n f System:
�
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc. _
Company
7. Location where contents were disposed:
G.L.S.D. II W to Ater
c . —r
Signatu d a ler Date
t5form4.doc^06/03 System Pumping Record •Page 1 of 1
Commonwealth Of Massachusetts E ( ...N...,...o.........
--
City/Town of . i �°
System mpin g Record
Form 4
y
IY J14 MWi:F=
DEP has provided this form for use by local Boards of Healt '� Ot j- det �r a sed�; 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 side of house, Right side of house, Left front of house, Right front of house,
-Left-i=ear of hotxse�Right rear of house.
Address V-1 hq1-2'6'14-A clut,'� �Uc) 4AJ
City/Town '�— State Zip Code 1`
2. System Owner:
Name -
Address(if different from location)
City/Town State "� ( °m�„ ip Cede
Telephone Number
B. tarr`tping Record
.� , ...�.
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑-l If yes, was it cleaned? ❑ Yes ❑ No
5. Conditioh.�Of System:� --
6. System Pumped By:
Neil Bateson
Name Vehicle License Number F5821
Bateson Enterprises Inc
Company
7. Locatign�where contents were disposed:
G:L. Lowell Waste Water
Si n ur of Haul Date
t5form4.docd 06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts w,
City/Town of m
i I r d't
System i Record
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 hare. 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 o h filling
the
lihout 1. System ocatio -
computer, use
only the tab key Address
to move your j
cursor-do not lrawm State City
use the return Zip Code
key. 2. System Owner:
VQ Name --- — — —
" Address(if different from location)
" Cade
Cit ll'ov✓n Stat,,r'l � � �
Y � �� P
Telephone Number
B. Pumping Record
1. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) "Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0' No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
6. Syste P mppd By
Name e°� °°"°' Vehicle License Number
Company
7. Locatio her contqqts w disposed:
Signatuv"Of.014 Date
t5form4.docm 06/03 System Pumping Record m Page 1 of 1
Commonwealth of Massachusetts
City/Town of I
System Pumping Record �i 4
Form 4
4
DEP has provided this form for use by local Boards of Health. The System i Pumping Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
When fllin 9out System o�ca tlon:
for ms on the
p uter, use ❑ t`6
-
❑ .-
only the tab key Address ----"-
to move your C ❑ ,� t '
cursor-do not
use the,return City/Town State Zip Code
.key.
2. System Owner: 1
Name ------- --- - - -- - -
Address(if different from location) --
City/Town Stat Z Code
- - --
Telephone Number
B. Pumping Record
1. Date.of Pumping Date---------" -- 2. Quantity Pumped: -- -
Gallons
3. Type of system: ❑ Cesspool(s) [ Septic Tank- ❑ Tight Tank
❑ Other(describe): — - - - -------
4. Effluent Tee Filter present? El Yes ❑ If yes, was it cleaned? ❑ Yes ❑ No
5. Condit* of Sy tem: \,
6. Sys#'e Wp�ed Name `� Vehicle License Number
w ..
Company ------ --
7. Locatio wIere conte s-w re di sed:
M. ,
— 06
Signal re er --- -- Date -- - ---
http://www.mass.gov/de /w to approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record •Page 1 of t
Commonwealth of Massachusetts
t
_ _ = City/Town of
a
— System Pumping a f`
Form 4
Al yY
DEP has provided this fora for use by local Boards of Health. Other forms may be used, but the,
infon-nation must be substantially the same as that provided here. Before rasing this form, check with our
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 W
for Important:s on t 1. Syste �catioq� .„��.,
forms�r�s�#ler�use t �
p - - `------- - - ----—-- -- - - - - -----to move your y t _ �� ! � � l "._...
only the tab key Address �J
cursor-do not ". � ,,., � r:�v _....�.� �-,M�"
use the return City/Town -- - - State Lip Code — ------
key. 2. System Owner:
-----------
Name ----- -- -
Address(if different from location) - -- ----
City/Town State - — L'p Code
Telephone Number
B. Pumping coIrd ...M,
1. Gate of Pumping -- Quantity Pumped:
Date Gallons
3. Type of system: El Cesspool(s) -teptic Tank ® 'Tight Tank
El Other(describe): -----
4. Effluent Tee Filter present? El Yes 0 o.... If yes, was it cleaned? ® Yes ® No
5. Conditi n of System:
—A-
C�
6. Syste Pu d Eby
C
Name _ Vehicle License Number
Company ----------- ---
7. Locatio re rnten are isp sed:
.w,
Sign r I aLiler
t5form4.doc4 06/03 System Pumping Record m Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: QUANTITY PUMPED : a�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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.® Lowell Waste
.. . " "
TOWN OF „( RECEIVED
S'EF1
T��W4l'F��+uR7HAny
DATE: µGc Tt'Aa_ i D . �I'
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: front of house)
e��gn le° left f�°
�
ItA ..,
DATE OF PUMPING: \ QUANTITY P LIMPED d GALLONS
mo
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE' OF SERVICE: ROUTINE , EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEAC +IEL D RUNBACK
EXCESSIVE SOLIDS FLOODED
DED
SOLIDS CARRYOVE,R OTHER(EXPLAIN)
SYSTEM PUMPE,ID BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: .L. ° Lowell Waste
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: - -
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
dd,q back 4- U�
DATE OF PUMPING: I I O d--QUANTITY PUMPED I fS 6t) 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 LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: 67 L
TOWN F NORTH
SYSTEM PUMPING
DATE:
SYSTEM OWNER &ADDRESS SYSTEM I,0CATI0—N
(example: left from of house)
_q 41'I 'AtA6
DATE OF PUMPING: ! .-0 1 QUANTITY PUMPED �Z') GALLONS
CESSPOOL: NO w,/ YES SEPTIC TANK: NO YES
NATURE OF SERVICE. ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GRE G,ASE BAFFLES IN PLACE
ROOTS LEAOIIF,IELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: --&Le
COMMENTS:
7
CONTENTS TRANSFERRED TO:
t
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADD RE SS SYSTEM LOCATION
`.a
(example: left front of house)
c_
k �at( 0,�eoxi v
DATE OF PUMPING: QUANTITY PUMPED 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: :�
Commoriwealth of Massachusetts
Massachusetts
p1""n trjjc Record
System 0%voer System Locatioit
Date of,flumpilig: Quafitily Pumped: 60
Cesspool: No IV Ves SepticTatik: No Il yes
System Pumped by: varedefe License #
Contents it-ansfiertred to : r Greate y LAsirld
L—L
Date: 111spector.
i
Cuuuttnutr�altl� of ftlarrninitusettr
Massachusetts '
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�j � 1 Qua�1111!' I'uutpfcll t �����
Unix or i'uu�t►Init � '` /
(,`ClsItlfllli ill ��`' �'C3
U firt,ll� '1'a��t t,I,' [j- Yes
1 '
a�eS LICetisd N:
srstettl 1 umved bv:
Cunlcnis lrnusletrr�l Irc �____�_� � .
1)nle 1►1sl�eClor
all
FORM - SYSTEM PL`.NfPL G RECORD
Commonwealth of Massachusetts
Massachusetts �,,°qp,
t
Svstem Pumpine Record
'stem caner astern ;-cation
w ...
/A
Date of Pumping: Quantity Pumped: gallons
Cesspool: No El Yes ❑ Septic Tank: No ® Yes E
� ., ._
System Pumped by.- � �. � License #:
Contents transferred to: ' ;.;
Date Inspector