HomeMy WebLinkAboutSeptic Pumping Slip - 10 OLYMPIC LANE 6/8/2016 ®mmonwe Ith Of Massachusetts
City/Town of JUL
Pumping r
Form 4 HU)LI i iDER�w&¢i�l
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 house, Left/ ►g side of haus Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address
t o
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stater i .° ;` Zi GO e
�4
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 E.3"No If yes, was it cleaned? ❑ Yes ❑ No
5. ConditioD 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
SignAtufe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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wl iu&iGr�DCommonwealth of Massachusetts
City/Town of � � '�
System Pumping Record
Form 4
iwwiuuvwiuw
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,�'ri ht side of hou e Left
G, _. _._
rear of house, right rear of house, left side of building, right rear of building, under deck_. ---
:;.
City/Town A State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State s -- Zip Code
Telephone Number
B. Pumping ec®r
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 J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lac tiort where contents were disposed:
G.L.S.D L ell WAtoWater
s..
Signatur o ler Date
t5form4.doc^06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts ... .... RECEIVED
'IVED
it /Ton of
w
0
System Pumping Record
Form 4 �Cffi'wl OF s lus NFH X\ )OVER �..
111.DER has provided this form for use by local Boards of Health. Other forms m .........�used, ., .h
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
Important:
1. System Location:
When filling out
forms on the
computer, use
only the tab key Address
to move your City/Towm
cursor-do not State Zip Cade
use the return
key. 2. System Owner:
0
ry
Name —
�enm Address(if different from location)
City/Town State _ Zi .„Code
<w
Telephone Number
B. Pumping Record _
1. Date of Pumping -bate Quantity Pumped: ,
Date Gallons
3. Type of system: ❑ Cesspool(s) E3 Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o ,.... If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: c
`'V nIF
6. Syste Rum ped By: _
Name Vehicle License Number
Company
7. Location wh co tentwpre I used:
signature of Kau43f Date
t5form4.docm 06/03 System Pumping Record.Page 1 of 1
Commonwealth of Massachusetts
System Pumping
Form 4
DEP has provided this form for use by local Board tt be used, but the
information must be substantially the same as that ravid�d€hC� `,Ne4sin this form, check with your
local Board of Health to determine the form they use. 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 LaCat10 � -LLY
forms on the ,y J
computer, use 1 only the tab key Address <
to move your
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
Name -
n Address(if different from location)
City/Town Stat �(�7)
Telephone Number
B. Pumping Record ors
1
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
C- �
Cher(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Con Rion of S stem:
6. Syst m Pumped By:
Name . Vehicle License Number
Company
7. Locatio Vrhe/re contents w disposed:
Signat a ul Date
t5form4.doc>06/03 System Pumping Record^Page 1 of 1
C.Ommonwealth of Massachusetts
City/Town of U _ TT .
System P6'mping Record
r` Form 4
2
CEP has provided this farm for use by local Boards of Health. T e,Sir ,nu:
be submitted to the local Board of Health or other approving aut ortyi��r,t�ri_r
A. Facility information - - __—_--
Important:
When fillin g out 1, System Location:
Y
farms on the
computer, use e ?
cursor•do not `~ _ ,..-..
only the tab key Address
to move our
- — = _ �_ !
- F .�. _
City/Town
use the return T __._.___,.._.__--
State
Zip Coda
key.
2. System Owner:
Name
Address(if different from location) -
City/Town
State
Telephone Number
Pumping Record - ----- --
"tom Date of Pum in ,� ;w_.._ A5,10
t�
p g pate —_� 2. Quantity Pumped. - -----------
p
Gallons
3 T pe of system, ❑ Cess ool s .❑�°§eptic Tank F-1 Tight Tank
°m ❑ Other(describe),
4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
61 Peem umped By;
vehicle License Number
Company _
7. Location where contents were disposed:
. .--____..__.__ pats �
Si ature of Hau
http://www,mass'.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc-06/03
System Pumping Record - Page i of 1
TOWN OF
RECEIVE
DATE: 01"0 .
e.IEAL I RI P,41'
SYSTEM OWNER AIDIDRESS SYSTEM LOCATION
(example:le:left front of hots �
(�J c t c:-
;1
DATE OF PUMPING: _� QUANT'IT'Y PUMPE ID : ---- GALLONS
C"ESPCDCDIam IC ' YES
CT ----
NATURE, OF SERVICE: ROUTINE, EMERGENCY OBSERVATIO S:
GOOD CONDITION IT°ION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS _ LEACHFIELD RUNBACK _ -
EXC'ESSIVE SOLIDS FLOODED
SOLIDS CARRYOVE R — OT HE R(EXPLAIN)
SYSl EM PUMPED BY. lRateson Enterprises, Inca
COMMENTS:
TS:
s'
CONTE TS T 1' SFE EpD TO. .Ln n Lowell WaSte -
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
�.,�� � .�� (example: left front of house)
DATE OF PUMPING: i o QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
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
COMMENTS:
CONTENTS TRANSFERRED TO: a _ ,b�;�,