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Home My WebLink AboutSeptic Pumping Slip - 481 REA STREET 4/6/2016 Commonwealth Massachusetts City/Town of d System Pumping Record ' , 1 VU, Form 4 11 A Y J1 DEP has provided this form for use�by local Boards of Health. Other form may,be;used, b 0/r;.e� information must be substantially the same as that provided here. Before sirs tiaisfrm, Chock with your local Board of Health to determine the form they use.The System Pumping itted to the local Board of Health or other approving authority. A. Facility, Information 1. System Location: Left/Right front of house, Left g rear-of hou sb, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Lc City/Town State Zip Code 2. System Owner: ( :Xf vwllk A Name Address(if different from location) Cityrrown State d ZR* Code '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 o 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. ocatipnw e e contents were disposed: G 's/ Lowell Waste Water Sign t e Haute Date t5form4.doc•06/03 System Pumping Record.Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping 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/Right front of house, Left ,i6trear-Qf.hou§tq, 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 dft t from location) own d�stat�9 4 p Code('S 6� Telephone Number VVj 'Tov t"'Ift 4i'MVIfig Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system- ❑ Cesspool(s) EJ Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑N If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Nell Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company . 7. Locgttion-w ,e contents-were disposed: Lowell Waste Water I y Sign toe qt Haule Date t5form4.doc-06103 System Pumping Record•Page 1 of 1 Commonwealth Of Massachusetts r City/Town of System Pumping Form 4 . a Sye TOWN r' LCt" OVLf DEP has provided this form for use by local Boards of Health. Other forms m W, i,t , information must be substantially the same as that provided here. Before using this orm, t 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 City/Town State Zip Code 2. System Owner: I Name Address(if different from location) City/Town State Zi Code Telephone Number B. Pumping Record G 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 0"Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 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. G.L S. re contents were disposed: ocat' n�__ ere Waste Water Sign to'e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ,� 1 % ` t. ��''t`),��I"()�ly�t'r^':+i't�,.,/�t, 1 1' Y t r i;, � • r%+t�: (9 RT 11� 11,W71� a„11„n+„+ . KfiWQ'Q t/ ( „ tA� cotd' � �.'�.'f �Ylv',��t I' ��'i� '1��' :','Td1�'(1i41,!bu•' I ,l ,ft I..Jdr J�d•ff�51 ;' Wit y qElR • 1 w.,, /i �Cu�ut l5l y,rv�ld � � ,r for for use by local Boards” f{ pith, The $,ystgm Pumping Recotc ba :ubmied to tho.local'6oard of Health or ,',rr,;,'+',., other approVlrig authority, A,, Faclllty lnfor 0n ,�,Lin ortantw System Loca ;•'� 'cornpul�r,use,1 ,, f� ��,� �kay 1 M tab + Addroas to mono your do OQI! Slab u :'1';'.;;.,r,5' ,: . ,• FP coda 04l�y�'` j 1+.;.4;'r'•.Y..E;I,;yl,�r.r'.' +1.Oq'?',r;..,'. �',�� , 1 ..e,t,•. ',. � 5i,r t1, .j��l �'r�l'r,'.1, 5'1 ��',' , , Addroas pf dlfforon! rom location) ti 1 Ctgr/T n d t'1 r Scala i,. Telophono Number trey p„y .•. ys i 2 Dat of Pu I' 2 Quan ty P � $ mping dal um _) ., :,•.;,,�,'.;''';;'1' ad pad :,,; Gallons lrYPo pf.aysf®m,, ' ❑ Cesspool(s) eptic Tank Tight Tan k r`r :; ffluatit T®� Pllt®C prgs0nt7.,❑ No es s It cleaned?�., I J 1 i5 Yes.® I(y was clean ❑ Yes ❑ No ' >5 , �, f r' 4} �v(•YtiJ 1<4 .fin/'(//QpY{�l II„ ! r / ,. .li° 1.',i1,'�t�;(�,•jp';.,Yr�'�YII�V®�VI,tJ®ni"C.li;✓y�r 1, IIY,i,,�'7i'�t�rl;,'„ � � � P.1 �...r ®I tl Sy PMped By, 'r ('I,..+^ ', �\'.(,'�4'!ti"'i's`"C;'',,t�'�`IQ/Y�a,11}l,l M'I:i•. q�il Vi :ll v, ,.,, .,�. " ,i<'';i' �il�•;I,l.'�t•:ny'aw�'i%�,�ff I;+Sj'ly�, ,.�1, !C 'I,.Gi� ' 5 .I�'LY�!M +t1",�,�';,. �r �yVyoyh/lcJa Ucon `,'Y;,.t,�r;,�.a;�r` 57�"hS��i tr�(;: tl�', u�X;. , ' It '�(' h' i V!�~' �. �'✓Jlf 'i8 NUrilbBr , 7rH'�if pi tY,;ri+rt;tl ��11•:r,�;�;;'�,, ,I,�.1;F;;;�,,',,.''7r,�s'<, an.wtier�' confencs' era I'', '. ,t',,n �/,..,' ';.Y"�I�Irr�'Y�'�'"1�•�:,,'"�if yf't,,171`i, ''(l.,�y'J•t�,\' !�(!,yr. t 4' �t. � Y�\,,� ,,,,,Y,, fl,'i>•,':14��,1 i'V.):�.4, 'a'..I{.,51 i,f. , '1IYII" \. �. '�Ji(r ,`('',��Y 1��1 7:111',,114,'i(Cr,,'1,t,,, r • i , ' ' 1rL.J Y +••J-C ' ' 'r r ♦'d lYi, ''�+• 'nr. 1',`, . f l'41) t15•' �1,' � e r � ! v.b tl5 Weis , , r http✓A�ww,mass,go , y p/vrater/apprQVaJs/t6(otTnslhtm#Inspect WomA,docy'08/QJ r ;t Syilam Pumping Rocoro Page nnionwealth of Cot Massachusetts City/Town of NORTH Systern Pumping Record u Form I ,r t has provided this tar to r use by local Bard of health. The t r�r,o a� i yr�y ord ntm, he submitted to the local Board of Health or other approving authority, A. Facility Information Important: When illing out 1. System Lo(attlon: forms on the computer, use only the tab key Address to move our cursor ;ity1 ow n y pr Zip Code the return t key, Sy 5 Owner: rr� v " Nearrro - Address(if different fi°rangy Iec;akiai7) Cityfrown State Zip mode relerahone Number ling Record � .`) 1. gate of Pumping k��t 2. Quantity Pumped: Gallons -- -- W I (•) �.. _ � �, ] Cesspool(s) �, . _.�.� Septic Tank [,._� Tight Trani �. o gem Other(describe): _ is ftluent. ee Filter present? Ye [ Pao If yep, was it cleaned? [_] Yes (.,_l No 5. Condition of Systerra; "q . r,, � °✓ Sys ern Purnped Ley 1 s F Vehicle License Number �r Company 7. Location where contents were disposed: r M M i Sipfiwture of Ft aulta d Date Iittp://www.rnass,gov/dep/water/ `�provals/t5forrris.litrraffirlspect t5forrM.doc-06/03 System i=utrrpinrt Rer:°orcl^Page 1 of 1 0 �m W .�"' ,m,.eta ,, U'` '.k S Y`3' h4 PIJMF'! � � .. . NO AD DA �s titi' ; r „ �. .._. YO McomgN !r . IG lJlr I �'lY I',� rll.�N,y1`tiK1�i31J ;� TOWN OF : . .., vat SYSTEMS F" J11'1AJx IF,�:C:'C)RL) vvk�q" .� . ip ;Y +1'EM OWNER & ADDRESS SYSTEM ECXA IICN Oorwe,ll N6 OlvyjoveW- DA TF C)I{� PLJMPINCJ. _ _._ . .... _.._QUAN'I"ITY PUMAFD CkSSE'UUI.: NC)__._., YEaS . SOptic I`unk: NO YE,S °" r NA FURS OF SERVICE: koU"C,INt „' FiMk;liC1N;N(.'1" OBSERWA f ioNs: ✓� GOOD CONDI'I'IoN FUU TTO DOVER HEAVY GREASE BAFFLES IN PLAC;L. ROOTS _. l " CHFIELD RUNBAC'K "CESSIVE SOLIDS FLOODED tiUE.ID CA KR YOVR p/IFER EXPLAIN Syat,otn Rumped by J`& /775.. So r(�✓C� i t UMMhN"I'S CUN I LN I'S FKANSI'LRRED ICS TOWN OF NORTH'ANDOVER .. + > T �PU PINS RECORD 5%*-")' "Eta OWHRR ADDRESS SYSTEM LOCATION " of house). exAm C� e: left tint ... •'G � ls:�TF OF PU1�1f.PINC: Q(!AN'I�Ifi`Y PUi ti�faD 5 1.1 taw, Ir♦y ' 51 UUL♦ NO Y 3. r � �SEPTIC NATURE OF SERVICE; ROUTINE EMERGENC t a I1>(?ft G OO�U COP IDI`I 10 �w 9 t, yyer(yap �/g■ COVE 4 f Pmmw FULL�RuA k HEAVY GREASE 13APF'LL-OS IN PLACE ROOT'S LEAtCHFIEL.1D RUNBACK EXCESSIVE SOLMS F"LOOOED SOLIDS CARRYOVER rp HE'R (EXPLAM) i 1°S°ITIM PUM PC. 13y: •> ?gip, s J c O N'I tvI E N TS, TRANSP0ItRE0 TO., TOWN OF NORTH A SYSTEM PUMPING RE DATE: ),ZADDRESS SYSTEM let f LOCATION SYSTEM gWNER & SYSTEM( p front of Douse) / p .9 P � .. �::.,:'" < •ac;�"�P /"e µ,SW py/ pp 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 Y• COMMENTS: CONTENTS TRANSFERRED TO: y�7� h t� '�t '�i�'1) f�r i'+u 4 *r�1 >, t�{Sl rt,; r I 1 u 9•r y ��r f b. I 1 _. � , 1 1✓{II 1 `7ti 4 f t. � r r , ,a n w .� + �. s�J.,y k J�7'}+r s�."r x y r+,r Ml�,4�i y r'�li fi{++�•;t 9�'r>:`g A«f t Y'�n!,.�,(F+.i.a; 7 N,4"AA{i t.r T 3�+1 dI{pr'i 15 7t�fl,i,''�,�+�»'1 1�I,1�u��M�ys,:rY�',°�Y"a;I'+fr�v�).{t q I.,'=1 tN 1�rdl'+n tY+1t�+'.'�i r qiI l',b t v"1>�tr-"ii•'i�I} , •f"'�Vt,'��..rt!h'i�h r M.t S"�l a.{!`�Ij p t�'{�r�'S��t�t�{,,,Y��AI��}c,I1X,'".t�'+�,!4.'",�M t�,�,'t`Jf4r,�>A t f,c y��I.t♦'G tIK.'r�r,�t d iat,,�,"R r a at�tri"''I�4^:v{.r��i^'r M 1 t r•'r,.."}'t NORTH ANDOVER SYSTEM p UMPING RECORD WX lys 11w I a};. SS rt1.I 0��'t1,rr f.!a+tr'r1 a"�d^e«,N++•�y,,b y,l' ri `�dr'f+•►"p��iy'. 'd � r,. �j �4f,'Y 0, a o "o f p "yry b i , ,p".N.I S Lt l � a YES SIMC' 1 ' ` i EMERGENCY la FULL'TO COVER r, VrN S IN pLACE WE SOLIDS `WULD RUN-BACK FLOODED Ali OTHER (v&LAN) 0 h 1 r h F kit x,. � . , � ,✓ ' u, i t�/{slt p®i I y, a " ,d� llP�.rq„",j 1