HomeMy WebLinkAboutSeptic Pumping Slip - 58 OAKES DRIVE 6/7/2016 Commonwealth lth of Massachusetts
� �
City/Town of � 1�04
a
y ter unpin 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 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, Left Right rear of housct 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:
Name
Address(if different from location)
City/Town State m.._ ,a
".� -Zip.Code
Telephone Number
B. Pumping Record
:.. ,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ®µ~ eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑yes ❑ No If yes, was it cleaned? ❑ Y--es-j No
_5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company ,
7. Location where contents were disposed:
"
G L 1 Lowell Waste Water
Lr �......... ( t
Sign t e Haule Date
t5form4.docd 06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusett
RECEIVED
u u
City/Town of
I System Pumping Record /PR
Form 4
OF NORTH ANDOVER
DEP has provided this form for use by local Boards 2414I°. a 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, Left Might rear of hgtse, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left f Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown Stat i ._ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped. L
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑peptic Tank ❑ Tight Tank
❑ Other(describe):
p ❑°Yes ❑Y No If yes, was it cleaned? ❑"des [
4. Effluent Tee Filter resent? .— ❑ No
5.__Condition of System:
6. System Pumped By:
Neil Bateson F5321
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-w er contents were disposed:
G.L S. ) Lowell Waste Water
Sign toe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
City/Town Of
System Pumping Record ?J)I I
Farm 4
FTrOWN L �� RTH AN[)t V R DEP has provided this form for use by local Boards of Health. Other for n
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-front_Qf house, right front of house, left side of house, right side of house, Left
rear of houK,right rear of hour§left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name �,
Address(if different from loci —
City/Town St at
Zip Code
Te ephone Number
B. Pumping ec®r
1. Date of Pumping Date --- — 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
U.-father(describe): -----
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? �No
5. Condition tem:
✓1 (5 r„
6. System Pumped By:
Neil J. Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc. _
Company
7. Loc io woere contents were disposed:
A.L.S.D. Wwel4aste W e
Signature oyHaA Date
t5form4.doc•06/03 System Pumping Record<Page 1 of 1
'oxm�immiuuwuamiiuiuuf�io�y ,," ," ,,.
ICN Commonwealth lth cif Massachusetts
City/Town of o-A N W w3 Z 0
System on
Fc�r�rt 4 t OW F NORTH ANDCWER
DE PAR ENT
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 front of house, right front of house, left side of house, right side of house, Left
rear of house-ri�g ht re �`C f hous!h,;left side of building, right rear of building, under deck.
C,�
City/Town State Zip Code
2. System Owner:
Address(if different from location) --
City/Town Sta
(Zip Code
Telephone Number
B. Pumping ec r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ®Septic Tank r ❑ Tight Tank
I Other(describe):
4. Effluent Tee Filter present? s ❑ No If yes, was it cleaned? ` No
5. Condi of System:
6. System Pu ped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location ere contents were disposed:
ISignat Wer Absteter
Date
t 5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
City/Town of "
a
System u vn Record
0r
n,
Form 4 l(fJ
DEP has provided this farm for use by local Boards of He Ithl iQ IEr,e rj m, ,,m ;,be used, but the
information must be substantially the same as that provided'here:13efo''re°uslri`gT 'is 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 side of house, Right side of house, Left front of house, Right front of house,
Left
rear of house,(fight rear of house. Left rear of building. Right rear of building.
Add-
tty/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
- — Z'ip Code
City/Town Stat p C /
Telephone Number 1
B. Pumping Record
1. Date of Pumping Date Wjep�tii uanti ty Pumped: Gallons
3. Type of system: ❑ Ce pools) c Tank ❑ Tight Tank
ther(describe): -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f System:
6. System Pumped By:
Neil Bateson F5821 _
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc tionmw,ere-contents were disposed:
L D Lowell Waste Water
g toe of Haul r date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
,C\ Commonwealth Of Massachusetts
City/Town of
System u pin or
Form 4 g
I�'E 4 2 a
DEP has provided this form for use b local Boards of Health. Ot er d abut the
p y ms m aybe use Y p � ��l nb ck with your
Information must be substantial) the same as that rovlded here local Board of Health to determine the form they use. The Syste Ptj submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System ocat
ion_: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of ho0e,,.Right rear of house. Left rear of building. Right rear of building.
Address -
City/Town " � State Zip Code
2. System Owner: _......w_
Name
Address(if different from location)
City/Town State
� ,..., ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑µ Septic Tank ❑ Tight Tank
❑ Other(describe): - -- - -
4. Effluent Tee Filter ❑
resent? "Y
p es ❑ No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc _
Company
7. Location where contents were disposed:
Lowell Waste Water
g to a of Haul r Date
t5form4,doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth „„
�►f � �h�� tt� w
City/Town of
System u pin g Record NOV 2 ,, 21108
Form 4 ra;:WP,101 (tK)R i H M iiaOV[.i�
DEP has provided this form for use by local Boards of Heal E other for b
Ith. ms mey�'e 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
Whenrfilling out 1. System Location: Left front, left rear, left side of house. Right front ..
ry�W ,t, right side
forms on the
computer, use _
only the tab key Address
to move your C ... ww ( c , , .m_
cursor-do not Cityrrown State Zip Code
use the return
key. 2. System Owner:
-----------
Name
Address(if different from location)
Cityrrown State i Code
Telephone Number
B. Pumping ecor
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspoo](s) .Q Septic Tank Q Tight Tank
Q Other(describe): - ---
4. Effluent Tee Filter present? S°es �] No If yes, was it cleaned? e [ No
5. Condition of System: f c
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water
r .
l _
igna ure of H Or Dat
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth oss s tts
City/Town
Pumping System
Fortes
DEP has provided this form for use by local Boards of Health. Other
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 forms on the
o use 1. System Location: C " "
tomove our .
only the tab ke y Address /
cursor-do not .�6
use the return City/Town State Zip Code
key. 2. System Owner:
ran Gil., f (/k
Name - -- ---
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping cor
1. Date of Pumping Date 2. Quantity Pumped: Lallans
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst m:
6. System Pum7d By
Name Vehicle License Number
6.
Company
7. Location where contents were disposed:
Signature of Hauler Date
t5form4.doc^06/03 System Pumping Record o Page 1 of 1
Commonwealth of Massachusetts
-- ity own Of
System Pumping cr
Form
4yy
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.'{
I
A. Facility Information -- -
T5 'i
Important:
When filling out 1. p System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not
use the°return CityfTown Stake Zip Code
..key.
2. System Owner:
t..W...
ra cr� l/ c)t
Name - -- — - --- —
Address(if different from location) ---—
CityfTown Skate -- ------
Zip Code'
Telephone Number
r
Purnpir g Recur
1. Date,of Pumping Date 2. Quantity`Pumped: c -- ---
Gallons
3. Type of system: ❑ Cesspool(s) Q-'Septic Tank ❑ Tight,Tank
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yes ❑l�o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syste P p d By; m_..
Name _ - - -
r
N Vehicle icense Number
Comparry
qf1 we're disposed:;
7. Locati n where contents
–� – —
Signature of Ha .!'r�-•�.�-_� ._. , � �,�A
g uler Date ---
htfp://www.mass.gov/dep/water/approval8/t5forms.htm#inspect
k5form4.doc•06/03 Systein:Pumping Record •Page 1 of 1