HomeMy WebLinkAboutSeptic Pumping Slip - 500 REA STREET 4/6/2016 Commonwealth
City/Town
o System Pumping
4
Form 4
UEP has provided this form for use=by local Boards 6f 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. Fac My Information
—
1. System Location: Lek �°Ight front of house)Left/Right rear of house, Left/right side of house, Left/
Right side of building, Le ig fPon o wilding, Left/Right rear of building, Under deck
Address - c
r�
CitylTown Mete Zip Code
2. System Owner:
Name
Address(if differ nt from location)
0 1 2114 .
City/rovun ' ;a.N^ 4 Mete r I, "�Y
Telephone Number
B. Pumping r
1. Date of Pumping ��te 2. Quantity Pumped: gallons
. Type of system: El Cesspool(s) eptic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? E] Yes Pilo If yes, was it cleaned? Yes No,
5. Condition of sy i s tam:
f��k � �
7
6. System Pumped By:
Pfeil Bates7on F5821
Name Vehicle License Number
Rateson Enterprises Inc
Company
7. aqption alt a contents were disposed:
S. 1 Lowell Waste Water
a
Sign toe Houle Cate
t5form4.doc®06/03 System Pumping Record m Page 1 of 1
Commonwealth of Massachusetts
City/Town of
Record
Form 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
1. System Location: Left Ig �front of ha , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Le _ g front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State;°°� 'p de
s
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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiop of Sys em:
... et
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc' , r G�
Company
7. Locztii re contents were disposed:
Lowell Waste Water
SignAtufe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
W
City/Town of I .
a Pumping Record
Form 4 `��� �
GSM Svt y`4v
DEP has provided this form for use by local Boards of Health. Ot is v� the
information must be substantially the same as that provided here. ck 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: Leff%Right frog of tacua 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
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State r Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Er Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0-190 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: `
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locat* where contents were disposed:
G.L, Lowell Waste Water
IQ
Sign toe Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Ith f Massachusetts
u w City/Town of
Pumping PI
r
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 forrrl 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: LefC�R�i g.ht ......._. ^'
Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left%f"lg1 ti"fronf®fPbuilding, Left/Right rear of building, Under deck
Address
, e-
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Rec®r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
( C7
,.
3. Type of system: ❑ Cesspool(s) ®°Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [D No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
' Lowell Waste Water
I V1 MA.
Sign toe I HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
RECEIV AID'
City/Town of
System u i ng Record 7�rwv
Form 4
TOWN I q� p ty p d p�
M svm v6v U 4dpll'�PowP&•"Wvd'i aS'"&W6"'N ANDOVER
PoRP .t"
R . 14 t"�; R I' E-NN'
DEP has provided this form for use by local Boards of Health. Other for
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 ear of house, right Left r of house, left sl a ran of�guse, left side of house, right side of house, Left
System ig o ui in , right rear of building, under deck. _
City/Town State Zip Code
2. System Owner: V0,U '�S
Name
Address(if different from location)
City/Town S# C � � aZ
Telephone Number
B. Pumping ecor
1. Date of Pumping pate --- 2. Quantity Pumped: 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: j (42-k1v-5-- �System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enter rises Inc.
Company
7. Location,WIhere contents were disposed:
LG.L.S.D. well Wa a, r
Signat r of auler ' t Date C
t5form4.doc•06103 System Pumping Record.Page 1 of 1
COi-nmonwealth of Massachusetts
� City/Town of .
'I
System umpire Record J
Form 4
d
DEP has provided this form for use by local Boards of Health. Oth r ,; k e
information must be substantially the same as that provided here. efoi-6' I p ���' 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
Important:
When filling out 1. System Location: Left front, left rear, left side of house Right fron right rear, right sid of Douse
forms on the
computer, use
only the tab key Address ° c '
to move your
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping ecer
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: 0 Cesspool(s) FJ Septic Tank p Tight Tank
Other(describe): - -
4. Effluent Tee Filter present? [j Yes o If yes, was it cleaned? ❑ Yes (I No
5. Condition of System: f
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•06103 System Pumping Record•Page 1 of 1
Commonwealth Ith Of Massachusetts
r City/Town of
Pumping System r
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 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:
_.. t
When n the
filling out 1. System Location-
forms o ` r C° 4 ° �5-✓ .
computer, use -----
only the tab key Address " 'a..,.
to move your —
cursor-donut Cityrrrnnm ------ State Zip Code
use the return
key. 2. System Owner: , fr
Name---
n Address(if different from location)
I
--
�i State ,C
y Q
Cit /Town /�1 �� �
Telephone Number
B. Pumping cord
1. Date of Pumping Date` -- 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) {j-eptic Tank ❑ Tight Tank
® Other(describe):
s'
4. Effluent Tee Filter present? El Yes .a If yes, was it cleaned? ❑ Yes q❑ No
5. Condit'o of System: C—) / ` It-)
6. System u ped By:
we Vehicle License Number
Company
7. Location w e e contents r re 's used:
Signature a er
Date
t5form4.doc<06/03 System Pumping Record^Page 1 of 1
TOWN OF NORTH V
SYSTEM PUMPING RECORD
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 LEACHF[ELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: d
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 3
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
'�
(example: left front of house)
CA..
DATE OF PUMPING � `� QUANT'IT'Y PUMPED �: � �" GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
Mr �
NATURE OF SERVICE: I$OUT'INE ME,RGENCY
OBSERVATIONS
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOT'S LEACHFIE,LD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CON'TEN'TS TRANSFERRED TO: