HomeMy WebLinkAboutSeptic Pumping Slip - 224 CARLTON LANE 6/7/2016 �N " I
VED
Commonwealth of Massachusetts
u ity/Town c
System I ng Record rw ruOR i �t r
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. Fac ility Information _
1. System Location: Left/Right front of house, Le I ght"rear of hone, 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
Telephone Number
B. Pumping Record
— c
1. Date of Pumping Date 2. Qu ntity Pumped; Gallons
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 pf System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo do _ ere contents were disposed:
7aL S. Lowell Waste Water
Sign t e Haute Date
t5form4.doc•06/08 System Pumping Record^Page 1 of 1
Commonwealth Of Massachusetts ..
City/Town of
YS
tem Pumping r
Form
UEP has provided this form for use by local Boards of Health. Ofher 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/Iigh "rear®f I?�se� Left/right side of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address
`Aj,Jo V'e
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
,' tom-
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
VvA ` `
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
.,
, ,,..,.�.
. , Y'.- _
G L' ./ Lowell Waste Water
I-VIOA
Sign toe 4 Haule Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth Of Massachusetts
City/Town of
System Pumping Record @offl'4b " 4NI Hih I18P APNq')4✓Vi 0R: `
Forma 4. HEALTH Ds a AF
4A/ 1Vi awmxr.reammmm¢m.,ruRmuunmT.ame imvm...aaumpipvxrm.m mmm.mwaorcn.
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 4,
„ right side of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
t
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
I - (act o 'A - --
Telephone Number
B. Pumping ecor
1. Date of Pumping 2 Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No 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. LocatiOn"Where contents were disposed:
G.L S, Lowell Waste Water
Sign to'e I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
K
Form
�fWtklPft)l �11'rHfi`flf� 7fr i�
fA H,f.mm.
DFP has provided this farm for use by local Boards of Health Other s 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
When filling out 1. System Cation:
farms on the
computer, use
only the tab key Address
to move your 1 Ja
cursor-do not C
use the return /Town Stake Zap Code
key. 2. System Owner:
VQ Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping cor
1. Dane of Pumping date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: f
Q
6. System,PumpedBy:
l c.
Name 4ehicle License Number
Company
�,, g M isposed:
7. acati wh re con nt s r
Signatur o a Date
t5form4.doc^06/03 System Pumping Record 4 Page 1 of 1
TOWN OF
SYSTEM PUMPING RECORD
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(exampl .left front of l ou"e)
j (a
DATE OF PUMPING: � } ...�� QUANTITY PU Eli m ' GAI.aI.C�NS
CESSP� OL: Ci._- YES_. _ EPTIC TANK: NO YES
NATURE ATURE F SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVED
HEAVY GREASE _ _ BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TS TRA. dSFER ED TO: G.L.S.D Lowell Waste
4
i
l V
TOWN OF NORTH ANDOVER
PUMPING SYSTEM
DATE: . q-._-1—(,
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
p (example: left front of house)
sc
DATE OF P'UMP'ING. ° `01 QUANTITY PUMPED J ,30 GALLONS
CESSPOOL: NO YES SEPTIC TANK; NO YES
e - EMERGENCY
NATURE OF SERVICE. ROUTINE ��
OBSERVATIONS:
GOOD CONIDITION FULL TO COVER
HEAVY C E ASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLILDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY.
COMMENTS:
CONTENTS TRANSFERRED TO. ...