HomeMy WebLinkAboutSeptic Pumping Slip - 39 PADDOCK LANE 5/10/2016 Commonwealth f Massachusetts
= i wn of
System Pumping, Record
Form
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: Leftd RRi�i t 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
City/Town State Zip Code
2. System Owner:
r
Name' j
Address(if different from location)
mcrr:ivED
CitylTown ' S tate 0 71 p,C fe-
Telephone--Number
OF 1,�,
B. Pumping Record
1. Date of Pumping Date 2. Quantity-Pumped: Gallons
,i
3. Type of system, ❑ Cesspool(s) eptic Tank ❑ Tight Tank
i
Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of tem:
keCam` Y\
6. System Pumped By:
Nell.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. La�tion w contents were disposed:
G L AHaule Lowell Waste Water
41
Sign t Date
t5form4.doc-06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
x City/Town of
Pumping System r
Forma
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
g g L6 Right front of building,Left/Right rear of house, Left/right side of house, Left/
1. System Location: Left R
Right side of building, L,o_ building, Left/Right rear of building, Under deck
Address µ ... 4.
or
City/Town State Zip Code
2. System Owner: c
Name
Address(if different from location)a
City/Town State Zip Code
Telephone Number
B. Pumping Rocard
1. Date of Pumping Date 2. Quantity Pumped: Gallons
... ._
3. Type of s y stem: Cesspool(s) �" a ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑°"°No tl If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
W
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where content,were disposed:
=1
0;.61 Lowell Waste Water
SignAtule qt HaulerU Date
t5form4.doce 06103 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
f City/Town of LNORT�4 y �te u pin eeord ;ruII Form 4� 1'0V%Q RRf�O R
DEP has provided this form for use by local Boards of Health. Other for ' rthi§
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
Y ight_fra�._._.�..- .
1. System Location: Left front of hou � rtt.af.hau�e, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
D
- --------------------- ----- -----
City/Town State Zip Code
2. System Owner: ❑ �� -
Name —----- .. ---- --
Address(if different from location)
City/Town State - ip Code
A t �6
Telephone Number
B. Pumping Record _.
M
1. Date of Pumping pate — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [3~' e'ptic Tank ❑ Tight Tank
❑ Other(describe): --------
4. Effluent Tee Filter present? ❑ Yes ❑moo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 4U�("
.❑ �, ti
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. La ation where contents were disposed:
-
G.L.S.
Lpqvell Wast lV14ter
Signatur6 of flauloy Date
t5form4.doc•06/03 System Pumping Record^Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping r RECEIVED
Foray 4 „p
DEP has provided this form for use by local Boards of Health. Oth Lforms may be used, bu the
information must be substantially the same as that provided here. �tfh i"thIIllGI ck with your
local Board of Health to determine the form they use. 'The System % 1iti " b ubmitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of hous `rlclit front„oJra �e, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
Cityrrown "ll StateU `✓ --- - Zip Code ---
2. System Owner:
Name - -
Address(if different from location)
City/Town State . — . dip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe): ----- --------
------ --
4. Effluent Tee Filter present? ❑ Yes ❑-,-No- If yes, was it cleaned? ❑ Yes ❑ No
s `>
5. Condit' n oSy1✓t te C
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location wher contents were disposed:
-"G.L.S.D. w I Waste Water,-)
Signatur of Sul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
RE V E D
Coi°nmonwealth ®f Massachusetts
City/Town ®f iN V 2 11:a 1 2
a w System in r
� •���I Ia
Form 4 �� A,I.��I �,I h���i r i�li �'i i
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 Location: Left front, left rear, left side of housK. Right front)right rear, right si of"hou
forms on the -
computer, use -
only the tab key Address
to move your
cursor-do not City/Town State Zip Code
use the return
key. System Owner:
Name
Address(if different from location)
Cit !Town State ode
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: p Cesspool(s) P-Septic Tank Q Tight Tank
Other(describe): — ------
p ❑ Na If yes, was it cleaned? �] Yes Q Na
4. Effluent Tee Filter resent? Yes
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:
_ (S.D Lowell Waste Water /
7f/_0_
r ^= ( 7
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record>Page 1 of 1
Commonwealth of Massachusetts
4
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 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.
® Facility Information
Important:
When filling out 1. System Location
... " ..
forms on the � �° '�.._��" •„ ,° " c-, a.� ��"�" .,,,�'
to move our '
computer, use
only the tab ke y Address r
cursor-do not Citylrown. Ste Zip Code
use the return
key. 2. System Owner:
VQ Name
r Address(if different from location)
Cityrrown Stat .v_ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑•-°Sbpfic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes El--N-6 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ,
A
6. System Pumped By.
Name Vehicle License Number
Company
7. Location where contents
were I osed:
1
Signature/of H er Date
t5form4.doc-06/03 System Pumping Record o Page 1 of 1
Commonwealth of MasChi tt
City/Town f � `a � E�'V E ., .
M1 o
System o
Form 4 101 11
DEP has provided this forth for use by local Boards of Health. Other for g ul i but _l
information must be substantially the same as that provided hare. Be.asng t s Ior h your
local Board of Health to determine the farm 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 y Location-
N, ( '
forms on the 1. System
computer,use
only the tab key Address �
J°'°1. .,
to mays your . .�
..e < ..
cursor-do not Citylr�owrr Stake Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
y/Town State ,." Cw. Code
Cit
Telephone Number
B. Pumping c Ir
C
1. Date of Pumping as#e 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑-Septic-Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑"'1Vo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f S tam:
ys
6. System P mped By:
Name vehicle License Number
Company
r
7. Locatlo where contents.
w dis p seed:
W
Signatur ul Date
t5form4.doc-06/03 System Pumping Record A Page 1 of 1
Commonwealth ®f Massachusetts
City/Town of
System Pumping Record MAY 2 '9, 'MO�
Form
O\AflOF PIC.) .'ri /,;•,iiiti`
DEP has provided this form for use b local Boards of Health. Other forms m be ' ; � �
p y y �� �but the--
information .
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:
K�
farms on the �. �, � ... ._ °,"- �'-`�,�,,,n,., a .�..,.�•�� .....
computer,use
only the tab key Address �
f ''.
to moue your .t � �f".
�,:„�,...� ��.. ,„� � � �....��..., �
t y.
cursor-do not - —
use the return Citylrown St a Zip Code
key.
2. System Owner:
M
Name .. - — - - ---
Address(if different from location)
CitylTawn Staten.-•-r �.�. .�. �� � �Cade
Telephone Number
B. Pumping r
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) E2"8eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes El”No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System P mp d By:
Name -" .- M Vehicle License Number
- -
”
Company --- -
p
7. ocation� ere.contents
.
-§719-nat,ffre ofH4uler Date
t5form4.doc•06/03 System Pumping Record 4 Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
C .v C-"kA+
T
'A
ka
DATE OF PUMPING: QUANTITY PUMPED SGALIONS
CESSPOOL: NO �--�YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVED,
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACH]I ELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
sysTrim PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANS]FERRED TO: G.L.S.D Lowell Waste
T '
SYSTEM PUMPING RECO"
DATE: „ 1
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of Lous
C � e
I C
DATE OF PUMPING: QUANTITY PUMPE D : GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUT INE , EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIE LD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(EXPLAIN)
SYSTEM PumPE D BY: Bateson Enterprises, Inc.
COMMENTS:
NTS:
CONTENTS TRANSFE RRE D TO:
TOWN OF NORTH ANDOVER
SYSTEM U !I l
t
DATE: _
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
-5 V
DATE OF PUMPING: 2. QUANTITY PUMPED_ ! ' GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
SS O OL• _
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACH FIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
/
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO: m�° /
TOWN OF NORMANDOVER
SYST E M PUMPING nCORD
DATE: ', ...„ I)
O W�NER & ADDRESS
SYSTEM LOCATION
(example: left front of house)
W o
A
DATE OF PUMPING;
= _ QUANTITY PUMPED ' GALLONS
CESSPOOL: NO __ YES
SEPTIC TANK: NO YES '"'
a
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
GREASE FULL TO COVER
ROOTS ------ BAFFLES IN PLACE
EXCESSIVE SOLIDS ~" LEACHFIELD RUNBACK
SOLIDS CARRYOVER ---` FLOODED ---- ---
OTHER (EXPLAIN)
SYSTEM PUMPED BY:
R
f�pr
'OMMENTS:
a
ONTENTS TRANSFERRED TO:
TOWN OF NORTH ANDOVE R
SYSTEM PUMPING RE CORI)
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:p left front of house)
w
DATE OF PUMPING: () QUANTITY PUMPED GALLONS
CESSPOOL:CESSPOOL: NO f 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: � ° N,
COMMENTS:
CONTENTS TRANSFERRED TO
FEI:l 2N
i
ComX"w
I Llo I M ass a c"us e I s
Massachusetts
System Owner System Location
gallons
Quantity Pumped:
Date of Pumping:
Cesspool: No Yes Septic Tank: No Yes
System Pumped by: Farm" 4F4&VM&" License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
Colljll oaavWf 1(h of MaSSUCIMSett.9
ass
5ystem I'luipp Record
System Owner System Location
Date of 11111117ing: Queatity Pumped: /'7 "gal'oll9
Cesspool: No Ves SelAic 'I'mik: No I-] Yes
System flumped by: varedda 53104141ma License
CotiteWshansficurredto : Oteater Lawrence Snuftar
I
Date: Ifispector
Coiyl Moll' ealtll OfWassachusetts
['A
Massachusetts
U1111 _LIppord
System Localioil
aA-
Date of,1111111phig: Quailtity Pumped:(
Cesspool: No V es Septic Talk No "des
System Pumped by: 97dredfy're License#
(I
'.mileii(s hansfiectred to : gLeg1wr—Lawrelne—squi—Itaffs
Commonw alth of Massachusetts
j
Massachusett C+
4
t rrr rr Record
System Owner System Location
o �
r
Date of Pumping: Quantity Pumped. ° allons
Cesspool. Now WWW Yes Ll Septic Tank: No IJ Yes _°°�
System Pumped by: Farcom 501 aeJ License#
Contents transierrred to : Greater Lawrence Sanitary District
Date: _ Inspector:
I
j
Commonwealth of massachuse(ts
..................
mass"'Ichusetts
&ig_Lj_qcprd
System Location
System OwLocation
QuablityPtmped:Date of Pumping: gallons
Cesspool: No Yes Septic Tank; No Yes
System License 11
9tell) I'llinped by
Contents hatisCeirredto : PLO-ter l-A-W—reINC
Date: Inspector
" k9k'JAL. i A 4 .w id L'r ,�
.
�;uN�tntiun�we�altlt cri!` �Mnssxtcitttsetts �° � � •� �`-� ��
Massachusetts �
„�m�� t� lt'�(`"rtte�tt���`""_•.�_.. ,�"""`�rj•�t��ii Liac�ii�ii..,..�_..._'_.__.._.
r --
bate of 1'riniping � � \ 7 C;1tM��tiltr 1"1�mtr dt t
Cesspool: N*U e U Fj Yes �..
�,I✓ a � __ ! —. License F�; —
S\•sient I'uml)ecl b\•:
Contents ►rensfertecl to.
Us�te _ Inspector