HomeMy WebLinkAboutSeptic Pumping Slip - 82 RALEIGH TAVERN LANE 4/4/2016 Commonwealth hu
v City/Town of .
YS
Form 4
DEP has provided this ford 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 Le -)/Righ r�arit of housed Left/Right rear of house, Left/right side of house, Left/
Right side of bull ing, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name g
Address(if different from location)
1
CityfTown Stat ..o I / i atle
Telephone Number a
i
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons —`
3. Type of system: ❑ Cesspool(s) 3- S tic Tank
Tight Tank
El Other(describe):
4. Effluent Tee Filter resent? w .
p ® Yep o If yes, was it cleaned? El Yes El No
5. Condition f stem: dd
6; System Pumped By:
Neil.Bateson F5621
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Loca' a where contents were disposed:
L S: Lowell Waste Water
Wgn Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record J,,0�4 1 14,
For 4 6�hWUsF
4 i iCrJ I(Q`1 r9„
1h AI 'dFfi
umvu,mn xt a +».. dux
DEP has provided this fora 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 forim they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatior>'Lefij%Rlght -:Uq house eft/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
C :..ICJ.
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' State Zip'�Code
l ,
Telephone Number
B. Pumping Record
Gallons
1. Date of Pumping Date 2. Quantity Pumped:
3. Type of system; ❑ Cesspool(s) ❑°Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Conditio of System:
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 Hauie Date
t5form4.doc>06/03 System Pumping Record o Page 1 of 1
Commonwealth of Massachusetts
City/Yawn of
Pumping System r [eUforetsing Form 4
DEP has provided this form for use by local Boards of Health. OthA ay,",bb but e
information must be substantially the same as that provided here. this form, the k with your
local Board of Health to determine the form they use. The System )RWdbfd M,@Sf � bmitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
Cityrrown State Zip Code
2. System Owner:
Name -- -
Address(if different from location)
City/Town State.. Zip Code
7;,
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):
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of ystem: Q (�
A. ,/c
6. System Pumped By:
Neil J. Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
,451. �A well"steWpte r
Signa u of auler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
,.k
Commonwealth of Massachusetts
LHOrAm C ity/Town Of
System Pumping Record ?
Form 4 DEP has provided this form for use by local Boards of Health. Ot 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 side of house, Right side of house,Gff front of house`Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of" , liu ding.
Address
City/Town 1. State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-8eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p El Yes ❑-'iVo If yes, was it cleaned? El Yes ❑ No
5. Condition of System:
6. System Pumped By:
_Neil Bateson F5821 _
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location whryere contents were disposed:
D� Lowell Waste Water
qgrPture of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
_
Commonwealth ®f Massachusetts `
. .. a.
City/Town ®f
System Pumping Record MAY 0 6 2009
�a Fora' 4 �� ()F i J ..
HEALTH i H I)EIPA�ANDOVER MEN
r
DEP has provided this form for use by local Boards of Health. Other formsIfYi°"'°"""""'tie u's'e`
Information must be substantially the same as that provided here. Before using this form ht e
. may � i
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 Locatio . Left front, I ft rear, left si of° ou�>Aight front, right rear, right side of house.
forms on the
computer, use _
only the tab key Address
to move your
cursor-do not Cityrrown State Zip 'ode
use the return P ti
key.
2. System Owner:
Name
«ri! Address(if different from location)
City/Town State Zi od
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) rj-Septic Tank Tight Tank
Ij Other(describe): —
4. Effluent Tee Filter present? Ej Yes No If yes, was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts ...
City/Town of
System Pumping r
Form
DEP has provided this form for use by local Boards of Health. Other onur�i Audi, but the
information must be substantially the same as that provided here. Before"using this forrn,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 LOCtion:,r c:'"; �° F G,, ,, � �•,} ❑~,... � r �� �
forms on the
r t ✓ ' 'LJt,,,, f
r ❑
computer,use
only y the tab key Address
to cursorgdonot ,. tt ... F .µ ... .. l .� ❑ r"(M.
use the return Citylrown State Zip Code
key. w .
2. System Owner:
. � w
Name
man Address(if different from location) �—--�— — — --- --
City/Town --- --- - -- State,.- ( , � .tZip Code
Telephone Number �J
B. Pumping Y°
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. .
T yp e of system: ❑ Cesspool(s) ❑ 5epti c Tank F-1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑�' o,. If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Systel um By.� '7I
Name Vehicle License Number
Company
7. ovation Mere content
s wer posed:
Signat A of a er Date
t5form4,doca 06/03 System Pumping Record 4 Page 1 of 1
Commonwealth f Massachusetts
City/Town of .1
Pumping System
Ftr IIa�J
CED has provided this form for use by local Boards of Wealth. Oth` f
r i t �;.
�� , it � ' a but he
information must be substantially the same as that provided here. ef&re,using-ht's fo-fth'�dh k with your
local Board of Wealth to determine the form they use. The System Dumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facility Information
forms on the
Important:
g 1. System Location:
When fillip out
µ -
c .C
computer, use
only the
tab key Address
to the
to move your
cursor-do not
use the return City/Town "_. State Zip Code
key. 2. System Owner:
VQ
Name -
roan Address(if different from location)
CitylTown State .�.. Zip Code
- C�.
Telephone Number
B. Pumping Record
1. Crate of Dumping ,Dane — 2. Quantity Dumped: Gallons
3. Type of system: ® Cesspool(s) peptic Tank ® Tight Tank
® Other(describe): — — —
4. Effluent Tee Filter present? ❑ Yes -No If yes, was it cleaned? ® Yes El No
h. Condition of System: a
6. yste mped By:
Name l e� Vehicle License Number
Company
7. Location where contents„" sed:
SignWof " — Date -
t5form4.doc^06/03 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts � 1; � �� �a
City/Town of I
System ur in a rd 4 �.
Form 4
DEP has provided this form for use by local Boards of Wealth. he'S'sb6ffi Pumpiing Record must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information _
Important: I f
When filling out 1. Syst } cat
farms on the
computer, use only the tab key Address (7) .
----- —-
to move your
use the return City/Town �. State � Zip Code
key. 2. System Owner:
R-7� Name _ � -"
fe6'" Address(if different from location)
City/Town —_ --- ---
Stat - --
09se
Telephone Number
I
13. Pumping Decor
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? ❑ Yes N,61 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syst m PuTperrd By �, –
Name
Name c
— --- ----- '
Vehicle License Number
Company ._ -- — --- -----
n �e disposed:.
7. Location where come ts w
,..
y f _
S n re o Hauler Date — -
http://www.mass.gov/de /water/approval8/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record>Page 1 of 1
TOWN OF
SYSTEM P PING RECORD
DATE: ' .._.
OR 11, 3 ?005
SYSTEM OWNER& ADDRESS
�� SYSTEM' LCDC T �
(example. left front of hoes
cvk
DATE OF PUMPING: a - > QUANTITY PUMPE IB : g�)i„i 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 LEAC RF IE LI)RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OT HE R(EXPLAIN)
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONT E,NTS TRANSFERRED TO: .La .D Lowell Waste
�f 1
TOWN OF
SYSTEM PUMPING 1�,ECO , -j--
OF ),Pt""
uowa—�
SYSTEM OWNER & AIDIDRESS SYSTEM
\ 1 V a (example. left front of house)
IDATE OF P ING d �,`w.. 1 — t..' QU ITY PU ETD : GALLONS
CESSPOOL: NO d YES SE PTIC TANK: NO YES
NATURE Or SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE,R
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEAC + ELID RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OT H'R(E L
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFE PME D TO: G.L.S.Dj Lowell rite
TOWN OF A.- 4&A'
SYSTEM PUMPING RECORD
,
DATE:
SYSTEM OWNER& ADD RE SS SYSTEM LOCATION
(example: left front of house)
l
DATE OF PUMPING: QUANTITY PUMPE D : 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 LEACHITIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PumPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TR NSrERRED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD hj"'?
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example. left front of house)
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:
T ~
CONTENTS TRANSFERRED O.
TOWN OF NORTH ANDOVER
SYSTEM PUMPING
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE CIF PUMPING: l )QUANTITY PLUMPED � � GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ' MIJRGENCY
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:
r
CONTENTS TRANSFERRED TC).
� ,
/Col xmwe Ilia of Massachusetts
Mgssac,liusetts
System r i
System Owner System Location
Date of Pumping: '0 Quantity Pumped: gallons
Cesspool: No Yes Septic Tank: No Yes
System Pumped by: Rredor6 910 edw License #
Contents transrerrred to : Greater Lawrence Sanitary District
Dale: _--- -- Inspector
('01111110 wealth of Massachusetts
, Massachusetts
� trt� f�ur �irl g Record
System Owner System Location
Date of Pumping: Quantity Pumped: gallons
�,
����,��-� Yes L� �....w.
Cesspool: No (.j�- Yes �_l Septic Tank: No �
System Pumped by: Fctredart cif ett� License#
Contents transferrred to : Greater Lawrence Sanitary District
[)ate: Inspector:
Comm nwealth of Massachusetts
' .�...� Massachusetts
��t�rn in g Record
System Owner System Location
.w
r .
r
c �
Date of Pumping: - " Quantity Pumped. ...a :.,����" gallons
��,�..�� ��°.��.,,....._ � Yes L°�.m.........�..�.,......
Cesspool: No ( Yes Ll Septic Tank: No
System Pumped by: aredoo 'Slre eje4 License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ _ Inspector:
Coomn onw alth of Massachusetts
n 4 /
yy
P , N1a SSUC;llustwlts
r rrr irr
9 Record
System Owner System Location
"LSA
<,. , e�,.
..
Date of Pumping; Quantity Pumped. � 4°� gallons
Cesspool: No ( Yes Ll Septic "Tank: No U Yes
System Pumped by: Fetrejert �rf iJW License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector:
Cor►amon weal th of Massachusetts
Massachusetts
Syslem Owtaea System Locatior►
7
Date of Ilumpir►g: ... �,��.. Quar►tit,y Lumped: "�� e,-) gallon►s
Cesspool: No Yes Septic Tank: No Yes
System Pumped by. gwejea License
t;or►lerats Rransl'er rred to : ra+sier w c t _ 1 �rlct
Date: _.__. _. ___...___,----- Inspector: _ _.�_ �._.._------------_._
t'rrt ��ti►f�v tflilt utk1amellugello
�� Mu��s�rrllus�U�
u
,q),01 toll C�wHel ----- --- `" Syffl�fl--1 �afClllitifi
Oen,
L�C
( 6 1—Y Oilditllly Pumped: � �frl�f�ill
Il�le t�l I ui►�l � 6 - l
t+rsspuc�l: N�► ( Yep L I �ltlie t+f�k: No
syalf'fn t' omped by: ettemd, coewtm
Cfsfflf��fl� Ifnffgl�ftt�tt Itf : �tebH�t 1.�wt�r►+����itll�t�t�liblel -���