HomeMy WebLinkAboutSeptic Pumping Slip - 15 NORTH CROSS ROAD 5/24/2016 Commonwealth
W City/Town
YS K5 NI
Form 4
CEP 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 form, check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
L k/ri de f hous.w
1. System Location: Left/Right front of house, Left/ rear of boos , g e )Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Uni er ec
Address w'
City/town Mate Zip Code
2. System Owner:
Flame
Address(if different from location)
Citylrown St Zip Code
Telephone Plumber
B. Pumping r _
1. Cate of Pumping 2. Quantity Pumped:
Cate Gallons
3. Type of system: Cesspool(s) Septic Tank ® °fight Tank
El Other(describe):
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? EJ Yes EJ No
5. Condition of stem:
AV
6. System Pumped Sy:
Neil Sateson F5621
Flame Vehicle License Plumber
Bateson Enterprises Inc
Company
7. jSignt ere contents were disposed:
Lovuell 1�/aste 1�ater
ere
Cate L
t5form4.doca 06/03 system Pumping Record®Page 1 of 1
Commonwealth of Massachusetts
d6fimul
_ City/Town of
System Pumping Record 7Y4 , rr,IE4
Form 4
'TOWN OF NONTH ANDOVE1,1
DEP has provided this form for use by local Boards of Health. Oth ��t4he
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: r front u r� front n ou e left side
rght side of house, Left
rear of hause right ear of house left side of building, rig f rear o building,
under deck.
City/Town State Zip Code
2. System Owner:
r
Name -
Address(if different from location)
--- --- - ---
City/Town State ' ( p Code l
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ept c Tank ❑ Tight Tank
❑ Other(describe): - — -- --
4. Effluent Tee Filter present? ❑ Yes [J-°No – If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lo 'cat.-wre contents were disposed:
G.L.S...b. _'LqWeI1 Wast s r
Signat a H ler `°°"" Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCAT IfDN
(example:left front of house)
'KoC)vk:c "s
DATE Or, PUMPING: QUANTITY PUNIPED
GALLONS
CESSPOOL: NO YES- SEPTIC TANK: NO_ YES
NATURE Or' SERVICE: ROUTINE' .s _ EMERGENCY
OBSERVATIONS: FULL TO COVER
GOOD CONDITION BAFFLES IN PLACE
HEAVY GREASE LEACIM' E LD RUNBACK
ROOTS FLOODED
EXCESSIVE SOLIDS OT HE R(E XPLAIN)
SOLIDS CARRYOVE R
SYSTEM PUMPEli BY: Batenon Enterprises, Inc.
COMNENTS:
CONTENTS TRANSF E RRE D TO: