HomeMy WebLinkAboutSeptic Pumping Slip - 73 FOREST STREET 4/12/2016 Commonwealth of Massachusetts
City/Town O
Pumping- •
Form 64
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/Right rear of house, Left/right side of house, Left/
Right side of building, Left 1 Right front of building, Left/Right rear(if building, Under deck
Address
City/Town State Zip Code
I
2. System Owner: C
Name'
Address(if different from location)
M, C U '`"�%�',t/Town State } Zip Code ;
Telephone Number
B.ping Record
4
1. Date of Pumping 2. Quantity Pumped: ~
Date Gallons Y
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, stem:
6. System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location- ere contents were disposed:
G.L S'. Lowell Waste Water
OA a� _.
Sign a Haule Date
t5form4.doo•06/43 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City/Town of
IJ
System Pumping Record MAY ll's .
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 e 'Right rout of house Left/Right rear of house, Left/right side of house, Left/
Right side of bui mg, Left/Right root of building, Left/Right rear of building, Under deck
Address XIA*
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown ' State - Z` Cods
Telephone Number �<
B. Pumping Record �µ
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 No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of V �--� �•, �� �� � �
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca'orrwl— contents were disposed:
aLs-p Lowell Waste Water
Sign t e Hauls date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
w
onnr�� onw lth f Massachusetts
ity//°1 own of moioio mm+�;YVYAkMi�k m7 1'flGwGO N✓ ❑ w
a
System Pumping cr ❑�❑
Form 4
DEP has provided this form for use by local Boards of
t t � cyused, but the
information must be substantially the same as that pro ide ,wh,;prgj fear ping th form, check with your
local Board of Health tQ determine the form they use. ie ys em umping ecord 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(Leff,front_of ti . ight front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
--
Address �`a`) .�.�� � C"�°Jw c. ?:� �_�--- �M� �,..�c'� (``�..,.✓(�i� c ��., .. .'�y ..y ..
City/Town State Zip Code
2. System Owner:
Name -------- —-
Address(if different from location)
------ -----
------ ------
City/Town State ,} Zip Code
Telephone Number
B. Pumping ecord
1. Date of Pumping [( -- -- 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) D`8 ptic 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:
Water
G L.S Dwell to��
.
-
Sig nature/f - —
�61 -- Date
-----
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
n City/Town of
System Pumping r
Fora
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: ^ry❑.,; �❑ ... v 1. ❑
When filling out Systety L0( t1: y
farms on the
computer,use
only the tab key Address
to move your ❑❑ � 4,.. .._.._ ,� "-1 ,,,
cursor-do not
City/Town State Z
� ip Code
use the return
key. 2. System Owner:
VQ
Name
Address(if different from location)
Cityrrown State ,, n 7. Zip e
Telephone Number
B. Pumping c®r �, ❑
1. Date of Pumping Date 2. Quantity Pumped: ba tons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ®-'14o f If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: f
6. Syst
em Pumped By'
Fs-
Name , Vehicle License Number
Company
7. Location here conitts e disposed:
Sign re uf�r Date
t5form4,doc•06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City
/TC)wt1 of I
System min Record _
Farm 4 r C�flw
Y,�4 S•y
DEP has provided this form for use by local Boards of Health. nh : y tai imkum'pIt'g..ReGord must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information --- -
Important; „
� ... �
When filling out 1. System Location: �"'
farms on the � � � � �.._ �"l"
computer, use
--° -... -
only y
the tab key Address
to move our
cursor-do not
use the-return Cityfrown State? Zip Code
key. 2. System Owner:
-iQ - ---— --- I,
Name – — —--
mom – --
Address(if different from location)
p-
Cikyffown State Code
Telephone Number
. Pumping Record
1. Date of Pumping Date- -- -- 2. Quantity Pumped: -
Gallons
3. Type of system: ❑ Cesspool(s) R'Septic 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 Pumper By:
, . ,
�M
Name , Vehicle License Number
Compan
7. Location Nre contents w re s
sed:
Signaku f ule date -- – – ----
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPINQ C;OR.L)
SYSTEM OWNIBIR& ADDR.ESS SYSTEM LOC'AT70N
6
DATE OF pU NQ;
-QOANTITY PUMPS®:,.._ .�?����
VLSS L: NOa , YES S00q Tank; NU YE.S
NA rUR�OF SERVICE; ROu'rINE.,,.. _.,•.�'M RUENC 1'
0bsF-RVA'rtON3:
OOOD CONVITIO1 , ..PULL To COVER
HEAVY ORWH
_ . ES IN PLAU,
AOM
BLa RUNBA 'K � �� �mm ,
OXC: $IV ,.._,
SOLIDS,...,.._tl FLOODED
SOt,It�CA YOYER OTN'ER EXPLAIN M WIF,1 5F NORI�-1 ANDOVER,
Sy.tam Pum d � �... .._
.� ....
....._...................�
5raallg& 177a.
VUMMENTS.
b ........... _.._........ ..... ........
vat
'rOWN OF NQR."1'1.1 ANDOVER
SYST-`iWi'P'11MPINO REC' RL) ��>vv��� f" i°���:x� ���:.c�
DA t t,
'.'.:p`..'r�
SYSTEM OWNER ADDRESS SYSTEM LOCATION w w IXT
23 Fa:�s7- ST DATE OF PGI�pINc :_ % . a U
CESSi'CJUI,: NO YES SOPtic I'xrrk: NO
hJ,A I"UKL OF SERVICE: ROUTINk. _. ._...I MIuliCil;N4'1'
OBSERVATIONS:
GOOD OD CONDITION FUU,'rU COVER
HF,AVY CRI-.ASE BAFFLES IN PLAU,
ROOTS
_-...._. LRACHMELD RUNBACK;
"CE SSIVE SOLIDS.____.__ FLOODED
SOLID CARRYOVER._... ,OTHER EXPLAIN
Systorn Purnpcd by so
C"0MMEN'l
c.'UN I LN I'S I"KANSEL-RILED 11) r
1 ,,,/ ,
TOWN OF NORTH A
SYSTEM
DATE: �2101 Viµ,
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house
r
DATE OF PUMPING: � �" �r` �,��. QUANTITY PUMPED l�� �� GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY -- -
I
i
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:
i
I
r .its
t + a
r
i
rr �
ff jj r
(r ,
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
SYSTEM OWNER ADDRESS SYSTEM LOCATION
(example: left front of house)
d f,. w fr a�
Orr ��� � 1� ef..
r c4
DATE OF PUMPING,- �� ro QUANTITY PUMPED GALLONS
r i � hwl, °,w<�
4
r ESS ' ®L. NO YES SEPTIC TANK.- NO YES
Ll
T"URE OF SERVICE. ROUTINE � EMERGENCY
6V I
�" t a vt Y Y tr�i r Y d r fr ti
u �M 1
�g�� tAl
rPQY� `�a ;ta &rryt'pra rr� i 17( � .�
ral 4ar�, Iti4r rt Myr r , r, N, I�� �` ', FULL TO COVER;C8t�
OD CONDITION
HEAVY GREASE 'BAFFLES IN PLACE
r
ROOTS
LEACH FIE LD RUNBACK
" EXCESSIVE SOLIDS
'L®ODED
` r SOLIDS CARRYOVER OTHER (EXPLAIN)
4
1r y
�j
�AaA� PUMPED 4
gyp) , R4y' f'r p" i'
"fiAwr/�r F '06o
4w„
✓ yy a 16 �ryry 9��� � � �' " r '
I
MMENT'Sa
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4p�r� � �A ,r�a4 4rrr7VgliiD �dtY ��� M r I � �I
TENTS r r
,F'A ����"�(�
rr�y per r I'M
ll y is