HomeMy WebLinkAboutSeptic Pumping Slip - 360 FOREST STREET 4/19/2016 Commonwealth of Massachusetts
W City/Town o r
�'j
System in Record h,
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 Locatio on of hou Left/Right rear of house, Left/right side of house, Left/
Right side of bu h , Left/Right rout of building, Left/Right rear of building, Under deck
Address
„.
A-kAJ
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
CitylTown ' State
Telephone Number —a
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. Condition "stem-
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. 7GL�Lon am re contents were disposed:
S. Lowell Waste Water
Sign At e I hlaule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
a
} System Pumping cr fib"
�a Form 4 � bwOF 1 �I1-h Feh�fl k�"IV ��
rc a mb� �l .ii
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 fortis 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 I ht front of
y house Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right fron of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State,�-�, `� -�. �;n rude
Telephone Number
B. Pumping ecord
1. Date of Pumping 2. Quantity Pumped:
Date Lallans
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Er No If yes,was it cleaned? ❑ Yes ❑ No
n of,System- 1
5. Canditi ..� ��/[/�
_K6,
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location w ere contents were disposed:
L S. Lowell Waste Water
j
Sign toe I Haute Date
t5form4.docr 06/08
System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts 7
City/Town of
System pig r °kc s% 0 9
Form
�a
DBP has provided this form for use by local Boards of Health. Other forms rhaitxi used,'.brat-ithe. .
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:
When filling out 1. System Location.
fo rms
n .
on the
computer, use ri •„
only the tab key
to mane your
.. ...
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name -- - ----
Address(if different from location)
City/Town — — State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) G"" eptic Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes p°Igo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
.,,, .. � ..w ��. � v
6. Syste P impqd By
'4�k
Name Vehicle License Number
Company —
7. Locatiopwhier con en
s were ispased:
Signature H 1 Date
t5form4.doc^06/03 System Pumping Record^Page 1 of 1
Commonwealth ealth of Massachusetts F
City/Town of I
System r pin Record
Form 4 �
i
DEP has provided this form for use by local BoardsW Health. 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 Loc
forms on the
computer, use
only the tab key Address - a� �- --
to move your �S—tate cursor-do not Git !Town — — - - -use the,return y Zip Cade
key.
2. System Owner: rl
I A
VQ
Name --- — — -- -- - - -
Address(if different from location) -- - — - --
City/Town --- State - Zip bode -- --
- ,�
Telephone Number
13. Pumping Record _—
1. Date.of Pumping = 2. Quantity Pumped:
�----- - --
Gallons
3. Type of system: ❑ Cesspool(s) epticµTank ❑ Tight Tank
❑ Other(describe): -- -- --------- .--
4. Effluent Tee Filter present? ❑ Yes ❑Noµ If yes, was it cleaned? ❑ Yes ❑ No
5. Condit'o of System:
6. Syste P ped By:
—
Vehicle License Number —
Company — --- —
.7. Location ere contents were di osed:
Signatur of a er Date — ------ - -
http://www.mass.gov/dep/water/ap'provals/t5forms.htm#inspect
t5form4.docr 06/03 System Pumping Record.Page 1 of 1
Copi'monwealth of Massachusetts
i
_..� Massachusetts
O '"T 9 2004
stem_.. _
Systern Owner � System Location
o
Date of Pumping: 10 0 q Quantity Pumpeel: gallons
y,
Cesspool: No [ Yes [I Septic.Tank: No [] 'des ["
System Pumped by: License ##
Contents transferred to: Greater Lawrence Sanitary-District
Date: _ _ ,Inspector:
TOWNOF IV� .
SYSTEM PUMPING
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left frout of louse)
�06
DATE OF PUMPING: / c��C " QUANTITY PUMPE D : � � � � GAS. ONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NAT URE OF SERVICE: ROUTINE, EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE _ BAFFLES IN PLACE
ROOTS LEACHF'IELTD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS S C YODVER OTHE R(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS TRANSFERRE ID T®: