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HomeMy WebLinkAboutSeptic Pumping Slip - 35 EVERGREEN DRIVE 5/18/2016 Commonwealth of Massachusetts City/Town 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: Left/Right front of house, Le Right rear of hou eLeft/right side of house, Left/ Right side of building, Left/Right front of building, a /-Rfg rear f�building, Under deck Address City/Town State Zip Code 2. System Owner: Name Address(if different from location) City/Town Stat C -ro l Zi 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 ther(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. Locati n..where contents were disposed: G L Lowell Waste Water Sign toe H Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 r4i � r on I s S ACHU tvjF �'.}I/��f`,J f)I i DEP hay provldA ;hla form for uao a Win' iluU�(o ll�v r 81 �onr�Ye of r z� � �r.�� T �ace Oc610 r , �vu ,r 41�r GEn�r aPpru,ln� ev(noriry, �, raclll�y Ir7forr7)aCion ------- -- LxaUOn; r Pumping Opt caw c! Pumping : 7 „ 3, �ypa p( by�l6m; Q C©ssro�t(s) RCIC TpnrE r'1 Tlrh, Y9^F, 4 �,. Etfl+ and ray �Ilra� pr�s�nr? : Y© . Own? L+ .+, a9 eana es �11 Q.Qndl,Uon,Q(sY�l m � Sy �(r1 P�'mped By YohkI B Junj4 On V,no(Q COf1lW3 6 c!,o, 3C. � � m8s 4,POYN OP AW lava PRO�aJaJ�6(orms.n�.��rr o v a....... .�. ,.... .,. .,....w., ., ..... 'P()WN Off°' NOR1"N ANQOVSf,, u a z f 1 yy .,.�.m. S`Y9TFM PUMPINQ RECOKL� SYSTEM OWNER & ADDRESS SYSTEM LOC'AT1ON DATE OF PVMMNQ: a 8 .. QUANTITY P . _ 0 t:0 SPOOL: No___ YES . ... 5opuc I'Xnk; NU, YES 'i " NA rVKU OF SERVICE: RounNE_ ObSBRVA' 10IS1a, ®CtJnaloN PULL, 'r'U COVER JUN 0 Koon VY — BAMBS IN PLAC;L. LW OXCR� MB SOLI R, „4 , MUD RUNBACK PlOODED .30LID CARRYOY'B _,..OTHER EXPLAIN by 177a. i `'UM MENTS. 4'4IN I'�N'I'� rKANSF'EkR.�I) I`Ca t SYSTEM TOWN OF T , CORD DATE: , A' -' (15 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (examples left front of house) 35 DATE OF PUMPING: � ` i�, w „ ^° QUANTITY PU ED e �. l� C� GALLONS CESSPOOL: NO � YES SEPTIC TA K: NO YE S -- NATURE, OF SERVICE: ROUTINE EMERGENCY ATIJI ._.._. OBSERVATIONS GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACH]'FIELD RUNBACK __- EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVE R OT +R(EXPLAIN) SYSTEM PUMPE IS BY: Bateson Enterprises, Inc. COMMENTS: CONTEN TS Tf3ANdSF'E ED TO: BOR,ICZEK'S SEPTIC & DRAIN SERVICiJ 10 Belmont Avenue, Haverhill, MA 01830 (978)374-3503 & 1-(603)329-6005 COMMONNkTHALTH OF MASSACHUSETTS / --4N b 0`� MASSACIIUSETTS SYSTE-TN'I RUNIPI G RECORD SYSTEM OWNER: SYSTEM LOCATION: l rte" Uytl2e� e- /V Nf�L)e-V 1-7 6_ �$ � 7�-'� 2 �'� uU DATE OF PUMPING: _ UANTITY PUMPED: _GALLONS: Cesspool:No Yes Septic Tank: No Yes 1 SYSTEM PUMPED BY BOR,A ZEE'S SEPTIC& nX4I N,SERV VICE Contents Transferred To: DATE: INSPECTOR: E, �I JlfV�U.lr P�R JG"4�144f I `J _ `e/' t