HomeMy WebLinkAboutSeptic Pumping Slip - 158 FOREST STREET 4/13/2016 Commonwealth of Massachusetts
City/Town of
System Pumping Record
t
,a�
CEP 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 t..r?.f.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
I C) 116 V-6L
CitylTown State Zip Code
2. System Owner:
Name
Address(if different from location)
ClWrown ' State Zip Code
�C.. " oo Rte__..
Telephone Number �t
B. Pumping Record
1. Date of Pumping ( � ( 2 Quantity Pumped: O
Date Gallons
3. Type of system: E] Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep 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
signitufe I Haule Date
t5form4.docm 06/03 System Pumping Record Page 1 of 1
IL
Commonwealth lth of Massachusetts
City/Town of
w
w System Pumping Record f
,t -
Forrn 4 �
M
DBP 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/might front of hou ( , 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 —
I <-
ll �
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State 77
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. Conditi n of System: -aA
U\-A
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locaf .tl.where contents were disposed:
G.L S. r� Lowell Waste Water
4Sign Haule Date
t5form4.doc•06/03
System Pumping Record-Page 1 of 1
_ Commonwealth Of Massachusetts
ity/1�aWn of � ryr�I'!I f � 6
System umpin Record
Form 4
9°A A t° i° 1Ai ' H AQ"1DOVER
DEP has provided this form for use by local Boards of e � icy used, but the
information must be substantially the same as that pro ' """M� "" g'ilhoga is 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 front of house rfg i frQnt.ofhou , left side of house, right side of house, Left
rear of house, right rear of house, le side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner: .-
Name
Address(if different from location)
.. .. ; .._ .� ,
City/Town State Zip C ode
Telephone Number
B. Pumping Record
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [1-Septic Tank ❑ Tight Tank
❑ Other(describe): - – ---
4. Effluent Tee Filter present? ❑ Yes R---No If yes, was it cleaned? ❑ Yes ❑ No
5. Condi on f System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location were contents were disposed:
❑°G.L.S.D
L4eIIWas4Aater
4Signatu a ler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
_ Commonwealth of Massachusetts
City/Town ®f
System Pumping Record RECEIVED
Form
J 2009
DEP has provided this form for use by local Boards of Health. Other fc ms may be used, but the
information must be substantially the same as that provided here. Bef ith your
local the laBal Board of Health or other approving 9 they authority.
System Pun pir��1e ����ti `�ub fitted to
A. Facility Information
Important:
When filling out 1. System Location: Left front, left rear, left side of housight fronts 'right rear, right s of house.
forms on the ��
computer, use
only the tab key Address
to move your
cursor-do not
use the return City/Town State Zip Code
key.
&_3 2. System Owner:
Name _ - - -- --
Address(if different from location)
City/Town State p Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) Septic Tank Tight Tank
Ej Other(describe): -
4. Effluent Tee Filter present? rl 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:
Z&6' Lowell Waste Water
Qft-J'A - (��'��
igna ure of H Or Date
t5form4.doc>06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts 1 �
City/Town Of I 111 J 2 200
System Pumping [(1P'/N'01 1 0� � 1/ y)M)v/i is
` Form i �t t, t
.. o.."
J
DFP 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 hare. 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:
p n. y,
When filling out . Y r...
forms on the System Location:
computer, use
only the tab key Address �. � '
to move our imp
cursor-do not City/Town State p Code
use the return
key. 2. System Owner:
Name
ter, Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping cor
1. Date of Pumping Da#e 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0--No--"" If yes,was it cleaned? ❑ Yes ❑ No
6. Condit* of System: V--e t'—
j
r
6. Syste Pu ped_.By:
Name Vehicle License Number
Company l
7. Location wPere contents were disp d.
Signature&ywul Date�'-
t6form4.doc•06/03 System Pumping Record•Page 1 of 1
Conunonw al(h of Massachusetts
. ��
Massachusetts
SvStem Puluving Record
System Owner System Location
Date of Pumping: ' Quantity Pumped: { `'` gallons
Cesspool: No Yes LJ Septic Tank: No Yes 14
System Pumped by: velredart S(Mrvrida License #
Contents transferrred to : Greater Lawrence Senitary District
Dale: _ ___ _ Inspector
TOWN OF
SYSTEM PUMPING RECORD
DATE: 'TO-
SYSTEM OWNED & ADDRESS SYSTEM LOCATION
(example: left front of house)
r�`c4 f
� t0
HATE OF PUMPING: i.� 1. ' � QUANTITY PUMPE D : [ ` .0 GALLONS
CESSPOOL: NO YES EPTIC TANK: NO- YE S
NATURE OF SERVICE. ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVED
HEAVY GREASE BAFFLES IN PLACE
FOOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPL
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
w�
CONTENTS TRANSF E RRE D TO. �
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
rv,
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example:p e front o ause)
DATE OF PUMPING: � QUANTITY PUMPED '" '"'"`GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE ",-,,
OUTINE ", EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIE LD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: