HomeMy WebLinkAboutSeptic Pumping Slip - 146 OLYMPIC LANE 6/9/2006 Commonwealth of Massachusetts
�rtrtrt Rw �
City/Town of RECEIVED
System i ng Record A.
r` Form 4
TOWN OF NOR1 F!ANDOVER
DEP has provided this form for use by local Boards of Health. Other for L �'
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 side Location: Right
building, h `r ar of hou®�
Left/right side of house, Left
Right of building, Left Right front of Left/R ht rear f building, /
Under deck
Address � _..l
City/Town `` �y State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State, A Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-9eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑`°No If yes, was it cleaned? ❑ Yes ❑ No
5. Condi ion qf System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.LgS. Lowell Waste Water
Sign toe I HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
O
r�►rn®nWealth Of Massachusetts ii �� I E-6
City/Town of 2O09
o
System ur in Record
Mq`
Form 4 . ma i c ��.T...
�i c xr ago.
DEP has provided this form far use by local Boards of Health. Other ....fo im �� y� be used, but the
information must be substantially the same as that provided Before umping IRecardfmust be submitted to
local Board of Health to determine the form they u System
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Let front, left rear, left side of house. Right fron , igh ar, �'ght sidaf a µ�
important: g t re u
When filling out Y
forms on the
---
computer,use —
only the tab key Address C .�: ,r �1 l c, -1 h w,,..
to move your ` State Zip Code
cursor-do not CitylT---"town
use the return
key. 2. System Owner:
Name
rclen Address(if different from location) _
State ip Cade
city/Town
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: Gallons
Da te
-
3, Type of system: Cesspool(s) " Se p c Tank Tight Tank
Other(describe):
es, was it cleaned?If [] Yes [ No
4. Effluent Tee Filter present? [] Yes Na Y
5. Condition of System: w -
6. System Pumped By:
F 5821 --
Neil Bateson Vehicle License Number
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Xigna DI Lowell Waste Water
Date
of H u r
System Pumping Record•Page 1 of 1
t5form4.doc^06/03
Commonwealth of Massachusetts -HUSE-TUTS
ANDOVER MASSAC
City/Town of NORTH
System Pumping Record
Form 4
Sy§tgm.'F!qjMpjnq.Reco d must
DEP has provided this form for use by local Boards of Health. T oni
be submitted to the local Board of Health or other approving aut YRECE VED
A. Facility information NOV 13 20OG
Important: j,/�j�DOVE,l-t
When filling out 1 System Location: TOVO4 0F"N(,) I I ME-.N I'
HEAL f i DETIAR
forms on the
computer,use
only the tab key Add
to move your
cursor-do not cityrrown State Lip Code
use the return
key.
2. System Owner:
Name
-Ad—dre�;—(if d—,ff—ere-ntfrom location) —
State Zip Code
City/Town
.�*-;7(2 -& 6 / 'S
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: E] Cesspool(s) 12"Septic Tank El 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:
4�a
6
Vehicle License Number
Name
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
System Pumping Record•Page 1 of 1
t5form4.doc-06/03
� '.: JI �,1!<x..F✓,yr, r�'1i,V, t �t LytyYl�;�' 't 1, �ti1��Yt f r,,1s,.: 't � '..
•--.._..-•---._...,.,.e,.o,,,., ' t .1o•W,11Y r11 ,J Y•J IP7:YY C I IbnJ'rr,
11,1ji1 ' I r�+''I b r{•i 1 r% r r 1t i ;r t^.»^^�^..v°..,. .«» - .,�.-•.>-,., _.,,_.._.,.
r 11 ,
( '�{��yf 1 "I tlJ�S(y(��"Y fi�t1, .tf r1r 7'� 1,�t'Stii/ f°��13if f� �'•' `I 1
!"df� � N"N!(�r" I,r',;u/ Z1 l �4�31 t! 4 alj, yli'�i•at
tl rJ! t"T7�17�1 +" f. , �7' `f 1.♦tif Y,rf'� f + 1
'r.l:'Sa,; ,15{� ;� !'`,w ,�, K 1 1� �•'• ��,r ' �SIR
a r yl lwr�l'� !
. , rk! ;te V"'1 Itl rr�:(�'�+�3�yCs1(r!"r �^17 vtt.�'���A','tf{�t,"4'1.i r ' �' r, +t, •
i�'�+t1
I ,c,,1,
1` r
li I t',r1 yf X1,1' 111 , t 151 Yr/fi rf I}. ,'II t c .',r, , •
,
,, xl��l 1 , ,v r it r; � �.•
P U K P I'N,Ga'. CC)
,
• ��'� f frf V 4 ,' J' k�' ( r � ' I
✓
M 1 N R: S.'Al D' l S SYSTEM t�OCrAT
' tit ,
moo,
(tx�m�le, lef� fronl of no��'<;
:7 777
AA
,+ � r7: t+.,�r{,YI I. J+ A 1 •, f r p h ,;, ,
' / �tw 11 it l Y� " wYl,"k �rF•'w''1"u,..6/ '�� ty � r
9 1 , Y 7'h 4 1 t
- NI ITY V r,
f�U Ifl
rt t
ay;7,t•"��f,'J fl�l7f ,jq.
- M1ir,rY1 41x1.}„ , '� • , ' '
N Of 1; ;� YES IS PT G',TANf< , N0 Y �
lilt
�i711,tia•ip
OF.,SCR`I`l.I,C ''ROUTINGMERCENCY
.(IiY��.rf,•••r%1t/gi�'';�r,l�r.r•'r,l l',�k'•4:�Ir ,' 1..-�..,
T,I�Q+ , bT..L L,'T 0'C U Y C i
l3 'F.I~'M` IN P l r A C l?
FACHP1C, D IZUNUACA,,
•- 51.D�r}� � r Y1 �( 1�y'ry�r I�1
r d: I(ly'i'�V WYYI,t 4'/`+';•7,�` Y 1' LO V,V 4(,/
Q s
''lull'; iR B (EXPLAIN]
Ulu
r
1 I1. I V IV y 4\ 1 y l 44k / 1
4 t (4 r }51 7F �,�
,. "t';t�,`417frh;,rv�v}5''�, f� ftE ,1)tl7il�r(FIN� r; 1.i`'�t\�4�d,�', }�,5�1,. �J,7Z{q,:'•�lY,.,•y,Lr,'tr� t � '�
" '.5'�f4i'X.,�it 5 4"rM vly�k /1 Sk j y71ir "� 11"O �•✓ d,Y ,f+G'tt{',t d.N I "1 ( t ,iv';t7 r r
• �t :
.'j!�'�'S�r�':�:yll�'1PUIrI,�1G.�"`aY�„•,. „':',. ,r. / 1 , ,Y,y;';' 'r I , rr
• 'r� r1'�'\r�1�•,t,;+ir),;.�'YR,I,�r !H/�'.r: t{ 1, y.,r „ ,r„
.,f ,.r Yh,f Js va r4 1 nl � ,•;.r.r, ,
,���i��l,{>'i�f� �l�(,�)
l,tf lt7 r(11. r Yi.i'�''•'fr Yrt'()rl�rej� tw��r`+�Y
�'l; f�''•'dt ', i,fy It,61y,,t.)� , /vy'� rt,i,� ,lill�:rlw}I��a,t` ,Yr .r
0 Vfa
q. r 4 f•''�1 1"ti, �I r't�I S,j 1 � � 1 4 f ��,� ”1 , r
'r���'�1'"f'��f t{'"����.i17�(a t�M'�l Il 41'r;'l.�r rl r •� � '' '
r 1 lii l"I% 3"fi1,',Y'Yrljri �1f I�ct I (' ,;•i: - a,. ,i��•'
7 :r, •'id r�•f;+P t , ' �,1 r7f y'C'I'.rq.,fJ,u: I � f ,
' ��.1/ I�4�.'�"'I11 11"I�"}'I:�II�1!I ,�'�Yi�I.IWY fl1UF ( 1 s '•1 v ilr , ,