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HomeMy WebLinkAboutSeptic Pumping Slip - 815 JOHNSON STREET 4/7/2015 Commonwealth chu u City/Town Of . System Pumping-Record Form 4 DEP has provided this form for use4by 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 Infer ation- , - 1. System Location L�W'Y Righ I rorit of iious d Righ of'h" housed Left/right side of house, Left/ Right side of building, Left/Rlg"fit cif ul Ina, Left/Right rear of building, Under deck Address Citylrown State Zip Code 2. System Owner: Name Address(ff different from location) City/Town E�°�� E state �.( � dip cads Telephone Number B. p° 1Yw"ti:i°�. Pumping e®r � ph, 1. Date of Pumping Date 2. Quantity Pumped: Gallons —�` 3. Type of system: ® Cesspool(s) eptic Tank S ® Tight Tank ® Other(describe): 4. Effluent Tee Filter present? Ej Yes o If yes, was it cleaned? ® Yes ® No, 5, Condition of System .w 6. System Pumped By: Neil Batesbn F5821 Name vehicle License Number Bateson Enterprises Inc Company 7. Location w ere cantenirs were disposed: U L S Lowell Waste Water Sign t e f Hauls Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of e F. System Pumping Record Form DEP has provided this form for us&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/Right rear of hous, Le /rig s1d"6 of hots Left/ Right side of building, Left I Right front of building, Left/Right rear of `I 1'ing, Under deck Address City/Town State Zip Code 2. System Owner: h Name' Address(if different from location) Citylrown ' State Zip Code Telephone Number r i B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: T Date Gallons t 3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑11410 If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition of System: . ,1 v ✓� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locanxhere contents were disposed: ASign AHaule Lowell Waste Water Date t5form4.doc•06/08 System Pumping Record>Page 1 of 1 Commonwealth of Massachusetts ���+ N�i� ° " ED , City/Town of pp pq System Pumping Record tj nM w= Form 4 'TOWN OF �i�uu��i�i A fl XYvr.:F DEP has provided this form for use by local Boards of Health Other farms 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/Right rear of house, Left/rdgtat rde of hau ,>Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address _" �'�/ ✓ .°. ,. RCS` ,.., a/ c City/Town State Zip Code 2. System Owner: o �a 1 Name Address(if different from location) Cityrrown State �.. .. d p;,Code IL � 1 .. 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? ❑ Yes ®No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ZS ZS 6. System Pumped By. r Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: S-P Lowell Waste Water Sign toe I HaulerU Date t5form4.doc<06103 System Pumping Record•Page 1 of 1 Commonwealth Ith ®f Massachusetts City/Town ®f System r Forme 4 DEP has provided this form for use by local Boards of Health. ht0l�l OF NOR'rF t the information must be substantially the same as that provided her tttf heck with your local Board of Health tQ 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 eft side of house flight side of hope Left front of house, Right front of house, Left rear of house, RigFit'�ear of fiause. Left rear of building. Right rear of building. Address -)C City/Town 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) L",1-S Tank S) ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of st�m: 6. System Pumped By: Neil Bateson F5821 - ---------------------- --- -------------------------------------- - Name Vehicle License Number Bateson Enterprises Inc Company r 7. Location wher e�contents were disposed: G w. L.S C_.- °: Lowe Water, - -- -- Signatu of � e Date V t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ` Cornmonwea|fh of Massachusetts _ �� �� City/Town ��/ System Pumping Record Form \ \ - i DEP has provided this form for use by local Boards of Health. Other s may be uoed, but the information must be substantially the same am that provided here. Before using this form, check with your local Board ofHealth to determine the form they use. The System Pumping Record must besubmitted to the local Board of Health or other approving authority. | | A. Facility Information Important: When filling out 1. System Location: Left front, left - -- Right fnont right �m on the 6�s--i � computer, use only the tab key Address � y ho move your oumnr-d»»pt City/Town State Zip Code � use the return key. 2. System Owner: Name A 'Ad—dress-Cif�ifferent from location—) � City/Town State Zi Telephone Number B. Pumping Record As 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type Vfsystem: Cesspool(s) F]"SeotiuT�nk�� [] Tight Tank Other(describe): 4. Effluent Tee Filter present? Yes If yes, was it cleaned? Yes NV | G. Condi ion of System- 6. System Pumped By: � NeUBateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatigji,where contents were disposed: n.L.S Lowell Waste Water igna ure;:of H u r -bate t5form4.doc-06/03 System Pumping Record-Page 1 of I `/ Commonwealth of Massachusetts 1 City/Town of I j dIs"J' 11 ! 2c�ct System Pumping o r Form 4 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: forms When on nin out 1. System Location: ° w" ' �..w computerth use ' _ ..,your only the tab key Address to cursor e y do not use the-return City/Town Stake Zip Code key. 2. System Owner: w_ p ---- . .. - - - - -- - Name — . - Address(if different from location) - � - City/Town ---- -------- - State ---- - -------- Z�r1 Code Telephone Number B. Pumpin*g Record C r_)J-7 1. Date of Pumping cafe — 2. Quantity Pumped; p _ Gallons 3. Type of system: ❑ Cess ool s ° p O ❑�'�e tic Tank� El Tank ` ❑ Other(describe): --- - - — — - — 4. Effluent Tee Filter present? ❑ Yes ❑ No If es was it cleaned? Y F] Yes ❑ Na 5. —Condition i0 n of Syste 6. Syst m P�umppd By ehicle,License Numb -- - —T ------ ---- :Name er Company ---- .7. Location here contents v e a disposed: sign r a f r -- -w Date------ — — - -- http://www.mass.gov/d / gat r/approvals/t5forms.htm#inspect t5form4.docc 06/03 System Pumping Record •Page 1 of 1 r ti, UA V . � Commonwealth of MSchusetf ,."..�.���.m���� City/Town of I .v. System um in Record ....... r Form 4 ItrrlT=I1�J� r� i .. 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: forms an the `` ..°. computer, Loca 1 t When fillip out st m y 4 - - - -— to move your V only the tab key Address -�-- cursor-do not --- _ r _ use the;return City/Town ---- State_l --- -- Zip Code .key. 2. System Owner: W„ Name --- - -- — - — - — — Address(if different from -- ca, City/Town - --- St a f - ---- -- - --- 1 � ` ,_ / . Zip Code Telephonie Nurnrei - — 13. Purnpin'g Recor -- 1. Date of Pumping Date — 2. Quantity Pumped: - Gallons 3. Type of system: ❑ Cesspool(s) 0, 86ptic Tank ❑ Tight Tank ❑ Other(describe): — — - -- -- — ---- - -- — — 4. Effluent Tee Filter present? ❑ Yes ❑'1�l ,....w.... "o If yes, was it cleaned? F] Yes ❑ Na 5. Conditio of Syste 6. System umped,By e c- Name ---- � Vehicle License Number Company — — 7. Locati n where contents w disposed: -r W Signatu of a er Date — -- --- — http://www.mass-gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc^06/03 System Pumping Record a Page 1 of 1 I 1 C')V'pi CJf NOR,119 ref-&I'.1c kV6.1.d E��';G"tiNSI Vdh E[EA l l f l"...... .. ... .. DATE SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) (") J'\�" 8-1\C DATE OF PUMPING: 0 QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC T NO YES r + NATURE l`IF SERVICE: ROUTINE EMERGENCY - OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD IIIT ACID EXCESSIVE SOLIDS __ ]FLOODED SOLIDS CARRYOVE R OTHER(E LAIN) SYSTEM PUMPE D BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.Dn Lowell ante TOWN OF SYSTEM PUMPING DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of hoarse) DA'L'E DF P ING< QIT TITY PU ED A - � .., GALLONS , CESSPOOL: NO ��E °. S SEPTIC TANK:I£: 1V® YES ems , NATURE, OF SERVICE. ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVE R HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVE R OTHE R(E LAIC SYSTE M PUMPE D BY: Bateson Enterprises, Inc. COMMENTS: . CONTENTS T SFE ED TO: .Le . Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION I (example: left front of house) < DATE OF PUMPING: ' - QUANTITY PUMPED SCve GALLONS i5 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: 2-- `> �� TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: r SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) � GALLONS OF PUMPING: ? LANTITY PUMPED CESSPOOL: NO , YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE " EMERGENCY OBSERVATIONS: GOOD CONDITION FULL, TO COVER IIEAVY GREASE BAFFLES IN PLACE ROOTS LE ACHFIE LD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM F'IIIVIP'ED 13Y: , COMMENTS: MIMENTS: CONTENTS TRANSFERRED TO: .,,� Commonwealth of Massachusetts A`-�&VM as sachusetts System r "In Record System Owner System Location Date of n =:I'um i f 1 � � ��"� � � '' Quantity Pumped: �� �°'' gallons Cesspool: No 1° Yes Septic Tack: No Yes L System Pumped by: License # Contents transferrred to : Greater Lawreme Sanitary District Date: _—`— Inspector.