HomeMy WebLinkAboutSeptic Pumping Slip - 268 RALEIGH TAVERN LANE 4/19/2016 Commonwealth u
u i own Of
YS
Pumping, r
Fora 4
I I 1
k
®EP has provided this form far 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
locos Board of Health to determine the forth 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 rig side of house]Left/
Right side of building, Left/Right front of building, Left/Right rear of bui dl ing, Under ec
Address ,
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Clty/Town ' State _ Zi Code
Telephone Number u
i
B. Pumping p c r
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? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition pf. stem: r
Lx,
r�
6: System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Sateson Enterprises Inc
Company
7. Location where contents were disposed:
�L S: i Lowell Waste Water
('3 ?4
Sign t e Haule Date
t5form4.doo•08/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts Lm:aye
City/Town Of
RrC
System i
sye�
Form 4� MH
DEP has provided this form'for use by local Boards of Health. Other form , u e
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 Lgji/prig sid� ousew`Left/
Right side of building, Left/ Right front of building;-Left/,Right rear of building, Under deck
Address <
_..._C#y/TCown ...,... .... 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 2. Quantity Pumped:
Date _ Gallons
3. Type of system: ❑ Cesspool(s) ® Sep It c Tank ❑ Tight Tank
❑ Other(describe):
s'.".
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condi 'on f System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati Tulle a contents were disposed:
L S. Lowell Waste Water
Sign toe Haule Date
t5form4.doc•06103 System Pumping Record>Page 1 of 1
Commonwealth of Massachusetts
x
City/Town of
System Pumping Record t
li�`a l
_ Form 4 .
'GSM
DEP has provided this form for use by local Boards of Healt but the
information must be substantially the same as that provided 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, right front of hous Jeff side
Y g g g, g�hT"rear"" b id'I'h"�� right side of house, Left
rear of house, right rear of house, left side of building, ri,,,. g, under deck.
to
City/Town State Zip Code
2. System Owner: >
y
Name ---
----
Address(if different from location)
City/Town Sta
Zip Code
Telephone Number
B. Pumping card
1. Date of Pumping Da{e 2. Quantity Pumped: Galion
3. Type of system: ❑ Cesspool(s) ❑, eptic Tank ❑ Tight Tank
❑ Other(describe): — - - - -
4. Effluent Tee Filter resent?
p ❑ Yes ❑"°'Na If yes, was it cleaned? F] Yes ❑ No
5. Condition of System: �.
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
G.L.S.DI. Lo ell Vila Water
Signaturd of a ler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
f�i�ttf�� I! � � �EVE um��imp
City/Town of ��.� �
System Pumping ecord
Form 4
TOW14 OF 0' D
DEP has provided this form for use by local Boards of Health. Other r R 0'
information must be substantially the same as that provided here. B 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 �' id of ho s6, Right side of house, Left front of house, Right front of house,
y r� Left
Left rear of house;"Ri' °hitTear of house. Left rear of building. Right rear of building.
Address -
City(rown State Zip Code
2. System Owner: 'Y
e
Name
Address(if different from location)
City/Town State j _ Zip Code,,,
Telephone Number
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 of System:
6. System Pumped By:
Neil Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatipn-wk'ere contents were disposed:
L Lowell Waste Water
�-160 A
g toe of Haul r 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
Important:
When filling out 1. System Locatio Left fro , left rear, left side of house. Right front, right rear, right side 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.
_ 2. System Owner:
----------=
Name
Address(if different from location)
Cityrrown State Zip Code
X55
Telephone Number
B. Pumping Record
1. Date of Pumping 1"Z ( L' '� 2. Quantity Pumped: -1—50o
Date Gallons
3. Type of system: Cesspool(s) E3/Septic Tank [] Tight Tank
Other(describe):
4. Effluent Tee Filter present? 0 Yes M/No If yes, was it cleaned? I Yes LJ No
5. Condition of System-
'N 0( /"MC`il l Ve� 1 Vl
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water
V10- -9 A �,�---t� -o igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth off SS ch RECEIVED
���tts �
it /Town of
Pumping System r
,
Fora 4 TOWN�CH,-'NOR�.l h rM DuV V°Ens
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 forrn, 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. Syst Locati011;
forms on the �.. �.. U ,e ✓ ° °
computer, use 111
only the tab key Address
-- G
to move your �� 3.._ � � °�.w�""� 'A(��
cursor- not
use the return City/Town S ate — Zip Code
key. 2. System Owner:
VG1 Name - — -
Address(if different from Nation)
Cidylrowm State C
Telep one 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:
s. system Rum By:
Name Vehicle License Number
�L>f
Company
7. Location w are contents tents vlere d" sed:
Signature a er Date
t6form4.doc-06/03 System Pumping Record-Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: L( ��x � UANTITY PUMPED f GALLONS
CESSPOOL: NO DES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHI IEELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: