HomeMy WebLinkAboutSeptic Pumping Slip - 37 CARLTON LANE 6/8/2016 Commonwealth f Massachusetts
City/Town oi
° "^ 2014
a
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. Facilfty Information
1. System Location: Left/Right front of house, Left i ht rear c f house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address 1
�ity/Town� Mate Zip Code
2. System Owner:
Name
Address(if different from location)
city/rown ' Mate' Zip ;ode
Telephone Plumber
B. Pumping Record ___...
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ® Cesspool(s) eptic Tank fight Tank
Other(describe):
4. Effluent Tee'Filter present? Yep PJo If yes, was it cleaned? Yes Flo.
5. Condition of yst m: rf�
t _
6. System Pumped By:
Pfeil Bates®n F5821
Flame Vehicle License Plumber
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
AS!gn S. Lowell Waste Water
U
f
e H oule Date
t5form4.doc9 06/03 System bumping Record®Page 1 of 1
CommanW Its ®f �hl� tt5 REC
City/Town ®f
OCT 2 2 ?013
t in Record
Form 4
HEALI'H DEPARTMENT
H
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 farm 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 teift rear of hots' , Left/right side of house, Left/
Right side of building, Left/Right front of building, Righ rr r of building, Under deck
Address--
City/Town State Zip Code
2. System owner:
Name
Address(if different from location)
City/Town ' State � °�� Zip Cod
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity 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 of System: r
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location w�. ,ere contents were disposed:
L S.Q Lowell Waste Water
SignAtufe Haule Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1
LN Commonwealth of Massachusetts
City/Town of
System u in g Recor
r Form 4 U(,' 1 O i,I
DEP has provided this form for use by local Boards of Health. Other form art
information must be substantially the same as that provided here. Before 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. Sy atio Left front house, building,house, right of houseLeft
,rear of hous right rear of house, left side of r ght rear of building, under deck l
c7 ry
City/Town State Zip Code
2. System Owner: `
Name —
Address(if different from location)
City/Town State Zip Code
Telephone Number t
B. Pumping ecor
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 present? ❑ Yes ❑''No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lac 'ia"here contents were disposed:
G.L.S.D. Lo II Waste,Watpr
Signatur of air er Date
t5form4.doc•06/03 ( System Pumping Record•Page 1 of 1
- Commonwealth of Massachusetts
o
City/Town of RECEIWED"-
System Pumping Record t
-- Form
1(")
'rOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other for !
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ 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-hous%-tight side of house, Left front of house, Right front of house,
Left rear of hous, Right reari-un tsee-deft rear of building. Right rear of building.
Address ❑ ❑
------ - —
City/Town State Zip Code
2. System Owner: f I �
-----------------------
Name ------- ---- ---- -
Address(if different from location)
--- ---- - -- -- -- ----------------- --
City/Town State -�-y ❑ p Code
Telephone Number
B. Pumping ecord _
r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) EI—9-eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? M r
p ❑ Yes No If yes, was it cleaned? El Yes ❑ No
5. Condition of System:'�(/�.��'�❑- �,...C�,.�C/��-~� � Ci°�.. /
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc _-
Company
7. Location where contents were disposed:
❑.. .
G L.S:D_w,❑ Lowell Waste Water
Signature of Hauler Date
t5form4.doca 06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System o
sv
Forms �' ', , e, rm
DEP has provided this form for use b local Boards of Health. Other fo s m�y�,b �i
p y y p using this�ornn butllh�' ...'�
it
information must be substantial) the same as that provided hare. Before°'° ,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 filling out 1. System Location:
forms on the
computer, use / _only the tab key Address p
to move your l.-,..(j
cursor-do not -
use the return City/Town State Zip Code
key. 2. System Owner:
VQ paAl
Name ----- —
Address(if different from location)
City/Town Stat Zip Code
Telephone Number
B. Pumping c rd _..
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) epiic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of�System: ¢W �
6. Syst m Pumped By:
LA-
Name Vehicle License Number
Company
7. Locatio here coats disposed:
signaluvb Ffauler Date
t5form4.doc•06/03 System Pumping Record m Page 1 of 1
�
TOWN OFVt SYSTEM PUMPING "CO"
DATE:
SYSTEM OWNED & ADDRESS SYSTEM LOCATION
(example: left front of aria
DATE OF PUMPING: QUANTITY PU PED a � GALLONS
CESSPOOL: NO YES SEPTIC I NO _ YES °
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVE,R
HEAVY GREASE BAFFLES I L CE
ROOTS LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER G'T +R(E LAIN)
SYSTEM PUMPE D BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: .Lm .D � Lowell Waste