HomeMy WebLinkAboutSeptic Pumping Slip - 199 STONECLEAVE ROAD 5/13/2016 Commonwealth of Massachusetts
City/Town Of
System u pin Record
Form 4
DEP has provided this form for use by local Boards of He I ,,91lanforms fm.y bO"4ed, but the
information must be substantially the same as that provid 'd her ;Bk yf irrg i `form, check with your
local Board of Health to determine the form they use. The e"m 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 house, left side of hour ,,right side of house,Left
rear of house, right rear of house, left side of building, right rear of building, under"d°cck p- ..
City/Town State Zip Code
2. System Owner: Yry
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. T yp e of system: Cesspool(s)ool(s) ❑'S e
ptc Tank El Tight Tank
❑ Other(describe); – -- - --
4. Effluent Tee Filter present? ❑ Yes ❑❑ No If yes, was it cleaned? ❑ Yes ❑ No
f y Q
5. Conditi on c� S�stem:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. ocation,wh re contents were disposed:
`"G.L.gD,, owell Wa e VVater
4
Sign tur ofj er date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts � � �..w. ,..
u City/Town Of
a
System Pumping Record
.. ...... ..... .. . „. ..
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 tQ 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. Lefttrea of ho'use,LRft Right rear of house I... ................ar of bull_._.. .
System side of houseLFt front of house, Right front of house,
g eft re W dmg. Right rear of building.
Address 4t ;V4
✓. t /�4 ° 4
Cityrrown State Zip Code
2. System Owner:
Name-- - ------
----------- -------- --- -- -
Address(if different from location)
City/Town St Zip 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
❑ Other(describe): --- - --
4. Effluent Tee Filter present? ❑ Yes o 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. LocatiortMhparp contents were disposed:
G.—LS.D, Lowell Waste Water
Signature of Hauler Date
t5form4.doc-06/03 System Pumping Record-Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System uµ �
Pumping
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
Important:
When filling
out System��, OC ation:
forms on the �
computer, use a /
only the tab key ddress �f.�
to move your y ` w
cursor-do not City/Town State Zip Cate
use the return
key. 2. System Owner: ,
Name !
n Address(if different from location)
City/Town State— tom..,, Zip 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
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 04o If yes, was it cleaned? ❑ Yes ❑ No
5. Condit' n o f System:
6. Syste umped By _....
, X\
Name Vehicle License Number
Company
7. Location wh re contents Were is Deed:
'Signatur`11,1u 61 Date
t6form4.doc^06103 System Pumping Record m Page 1 of 1
TOWNOF
SYSTEM PUMPING A CORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of heaves)
'(y
FA'I'L OF PUMPING: QUANTITY TITY P EID : -- GALLONS
CESSPOOL. NO
YIS SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE _ EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE R
HEAVY GREASE A L IN PLACE
ROOTS LEACH MELD RUNBACK
EXCE SSIVE SOLIDS FLOODED
SOLIDS CARRYOVER. OT +R(EXPL
SYSTEM PUMPE TD BY: Bateson Enterprises, Inc.
CO IE Sm
CONTENTS TRANSFERRED'TO: .L® n Lowell
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: . L)
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
7R &ADDRESS
SYSTEM
(example: left front of house)
f
DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO ,,///YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LE ACHF MELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
-'
SYSTEM PUMPED BY: A
COMMENTS:
CONTENTS TRANSFERRED TO:
('01111110mv 'alth of,Massachmeth
�jyAtevri F'uuvi&jg-.Re cord
.............
yraRerrr 0 System Location
Ci
Date of Pumping: Quailtily Pulliped: 911110119
Cesspool: No I v es [J SepticTatik: No yea
System Pumped by: Faredea License
Coti(entshansf�irredto : Oventer
Date: ➢tispeclor
tlµ ;
e
w
fS
spural, No ("" ves Sepliu `1'mok: No Yes
Sy"kill 1111111ped by; t ,040Ps rove Licellse
a
n