HomeMy WebLinkAboutSeptic Pumping Slip - 105 CARLTON LANE 6/8/2016 Commonwealth of Massachusetts EMED
u City/Town Of
14
w Sys, tem Pumping 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. Right side of building,eft/Right front of hoes , L ' ! i hktt.r of h ,..
System g e tJ `g tea -°U Left/right side of house, Left/
g ng, Left/Right front of bui ding, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown ' State � � . .�...� c�tl �2ip Co �..� � ,.,� '
(' _w.
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type of system; ❑ Cesspool(s) ❑-"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p E] Yes ❑,'� If yes, was it cleaned? El Yes ❑ Na.
5. Condition of Sy to
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati n- ere contents were disposed:
G LS Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
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Collanionwcalth of Massachusetts MAY 2,' 2()�T
CitY/TO rn of � ") 4�/ ") .
HEALTH 6EPARIME,NT,,,
m
System Pumping Record
7'acililY Information:
System Location:
Address
— ,f
6Jty/Towfl� ,.� O
State Zip Code
System Owner-
Name: PPp �d
Adress (4-dfliTerent from location o pump)
City/Town '`
State Zip Code
Telephone Number
Pumping Record ---
Irate of Pu
min
p (quantity Pumped � ` �" °� p-allons
Type of System �
Sep tic Taal grease Trap Daher (what)
y
System Pumped by: .
C°orrapany: ROOTER-MAN 12]fast Dracut Rd., Methuen, MA 01844
Location where contents were disposed: F'Ii/
Signature of Hauler
. �F
mate
1
TOWN OF
SYSTEM PUMPING RE, CO"
DA'Z'E: C..
SYSTEM OWNER ADD RE SS SYSTEM LOCATION
.. (example: of Moores)
AA
DATE OF PUMPING: --- QUANTITY PUMPE D : GALLONS
CESSPOOL: NO YES SEPTIC'I NOD YES
NATURE OF SERVICE: ROUTINE, EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE R
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHF,IELD RUNBACK
EXCESSIVE SOLIDS _ FLOODED
SOLIDS CARRYOVE R OTIHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTE,NTS TRANSFERRE,D TO: .Lo . ....... .. .............Lowell Waste
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
Y
DATE OF PUMPING: ' QUANTITY PUMPED ( 'S b') GALLONS
i
CESSPOOL: NO YES SEPTIC TANK: NO YES A/
NATURE OF SERVICE: ROUTINE , EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK.
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: F.. � ° > ` .......
COMMENTS:
CONTENTS TRANSFERRED TO:
C ommolmr,altli of I' asssc husetts
-Lipcord.-_
System Owner System t-,ocation
I
Date of Pumping: 9tiaiitity Pumped: -,gallons
,
Cesspool: No 14 ves [_J Selitic Tsiik: No Yes
System Pumped by: Feiredea License #
Coiiteiits haiisfeirred to : Greater Lawrence MOM DI IrlcQ
Date: _---_-- -____-- _ irispector