HomeMy WebLinkAboutSeptic Pumping Slip - 121 OLD CART WAY 5/16/2016 Commonwealth U seft G,
u u� it f
S * tam Pumping YS
Recordt
Form
z
DEP has provided this form for 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 fora~, check with your
local Board of Health to determine the form they use.The System Bumping Record must be Submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Let„ ht front of
house Left/Right rear of house, Left/right side of house, Left/
Right side of building, Leh--/—F-Zig-h1 uildifig, Left/Right rear of building, Under deck
Address � � C � �, - G'� �,_,, =��-�...-✓ <"�,;,
City/Town Mate Zip Code
2. System Owner:
Name
Address(if different from location)
Cityfrown Mate Code
-- ..� ,
Telephone Number �'
B. 7
Pumping cord
1. Date of Bumping rate 2. Quantity Bumped: canons
3. Type of system; Cesspool(s) 018eptic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter presentI Yep o If yes, was it cleaned? Ej Yes Ej No.
Condition of System: 4�
6. System Pumped By:
Neil Satesbn F5821
Blame Vehicle License Number
Bateson Enterprises Inc
Company
7. Location,where contents were disposed:
jign S. Lowell Waste Water J
G c L�
e Houle Crate
t5form4.doca 06/03 System bumping Record Page 1 of 1
ommonwealth Of Massachusetts
4 City/Town of
Pumping r
y,
' Fora 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 farm 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 kFight front of house 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
I
2. System Owner:
Name
Address(if different from location)
City/Town State + i Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Qu ntity Pumped:Date 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. Conditio of stem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign to a Haule Date
t5form4.doc•06/03
System Pumping Record-Page 1 of 1
_ Commonwealth of Massachusetts
W City/Town of
System Pumping Record d �`� ��m
,A Form 4
DEP has provided this form for use by local Boards of Health. Other forms ayr,�,b,p,i
information must be substantially the same as that provided here. Before usilfrwy chtuwtthw ur
local Board of Health to determine the form they use.The System Pumping Record must a submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of hous , right front of house jeft side of house, right side of house, Left
rear of house, right rear of house, le s1"d g,right rear of building, under deck.
Njo
City/Town State Zip Code
2. System Owner:
Name - -
- - ---------
Address(if different from location)
City/Town Stat Zip Code
Telephone Number
B. Pumping ec r
1. Date of Pumping µ— (� 2. Quantity Pumped: !
Date Gallons
3. Type of system: ❑ Cesspool(s) [9"Septic Tank ❑ Tight Tank
❑ Other(describe): -
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
VV-- -- e."(' "jj-S --
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
L.Sb Lowell Waste Water
Signature of Hauler Date
t5form4.doc^06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
x
City/Town own of I
r ..
System Pumping Record
Form 4
r, i ��
DEP has provided this form for use by local Boards-of Health. The Sy tem" u, °Ihg R ded rriust
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important:
filling When System anon; .._.,.
forms on use t 1. S Stem t� Gu' u.� -/ A �
"!
to move — - -- — ---- '
x
our
cursor-do not
on the to key Address .
use the return Cityrrown State T Zip Code
key. 2. System Owner:
Name — — -- --- -- --
Address(if different from location) —---- ---
- -- -- --- --- ------------
ity�Town try,... Z�i Code'
Std � 1'"�
Telephone Number —
13. Plumping Record —
1. Date of Pumping 2. Quantity Pumped:
Gauons --
3. Type of system: ❑ Cesspool(s) [;J-Septic Tank ❑ Tight Tank
❑ Other(describe): --- ---- ------ ------_ --- _ -
4. Effluent Tee Filter present? ❑ Yes ❑ ' to If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio n of System:
\(')Voukrd) klxlo
6. Syst m Pl mped By
¢-
-- -----
Nam -- ---- ----
e rc � Vehicle Licen§e Number
—
Company --- - -
7, Loc turn where cant nt�,w disposed:
.. �,„;,.,
--_
Z—of Signat ul r -- — — Date -- -- —
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•(76143 System Pumping Record•Page 1 of 1
v
1
i
TOWN OF
SYSTEM PUMPING RECORD
I
SYSTEM OWNER & ADDRESS SYSTEM LOCATIO
(example: left front of house)
0 61
DATE OF PUMPING: -������ �.
-- .,�. �� .� QUANTITY PUMPE D : GALLONS
CESSPOOL: NO YES SEPTIC T K: O YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE'R
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R O'T +R(EXPLAIN)
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFE ED TO: .Lo . Lowell Waste
AVED
TOWN OF
SYSTEM J I
ANDOVER
DATE:?
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of lJouse)
1 �
DATE OF PIT ING; QUANTITY PUMIPE D , _ GALLONS
CESSPOOL: NO SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE,+ EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE R
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIMELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R OTI.1ER(+ L
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS T STS+ + +D TO: .L4 o L Sd t
( I
FORM 4-SYSTEM PUMPING RECORD
SEPTIC & DRAIN SERVICE
107 FI ST STREET;.MIDDLETON,MA 01949
(978)774-2772
COMMONWEALTH OF MASSACHUSETTS
/vim. A Y, dej yc MASSACHUSETTS
S YS TEM P UMPING RE CORD
SYSTEM OWNER: we (t SYSTEM LOCATION:
0 Co,f4- w&s-(
79 q
DATE OF PUMPING: " �G� QUANTITY PUMPED: / GALLONS
% ��� 1 : NO YES SEPTIC TANK: NO YES
Alle�Y� 'UMPED BY: CURRIER SEP'T'IC & DRAIN SERVICE
C6 SFERRED TO:
DATE. I =C INSPECTOR: O -- _
, ,-.,%'
FORM 4-SYSTEM PUMPING RECORD
CURRIi
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON,MA 01949
(978) 774-2772
f
COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
S YS TEM PEM.P'.ING RE CORD
SYSTEM OWNER: SYSTEM LOCATION:
,tm f /, �or ���1��
/ CCU 7 ct- of- 6
DATE OF PUMPING: ` �� QUANTITY PUMPED: � � GALLONS
CESSPOOL: NO E::] YES SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: INSPECTOR: